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AN 

INTRODUCTION    TO    SURGERY 


AN 

INTRODUCTION     TO 
SURGERY: 


RUTHERFORD    MORISON, 

M.A.,  M.B.,   F.R.C.S.   Edin.  and  Eng. 

Professor  of  SuriT cry.  University  of  Durham  ;  College  of  Medicine,  Xewcastle- 

tipon-Tyne ;  Senior  Surgeon  to  the  Roval  Victoria  Infirtnary. 


With   146  Illustrations  in  the  Text,    and  5   Coloured   Plates. 


NEW     YORK  : 

WILLIAM     WOOD     AND     COMPANY 

MDCCCCXI 


'^ 


jAt. 


^-6l 


PREFACE. 

The  excellent  surgical  textbooks  now  available  for  the  use  of 
students  have  given  rise  to  some  doubts  as  to  the  need  for  any 
further  instruction  by  means  of  systematic  surgical  lectures. 

My  own  view  is  decidedly  in  favour  of  a  course  of  lectures, 
provided  that  they  are  not  mere  abstracts  from  the  textbooks,  but 
are  directed  rather  towards  those  main  principles  of  diagnosis  and 
treatment  that  are  based  on  a  sound  knowledge  of  pathology.  They 
should  be  aids  to  the  student  in  thinking  out  for  himself  those 
pathological  and  diagnostic  problems  that  are  presented  to  him  in 
the  wards  and  in  the  textbooks.  In  order  to  do  this,  he  must  study 
these  General  Principles  and  understand  the  value  of  their  universal 
application  in  so-called  "  special  "  regions,  that  is,  to  diseases  affect- 
ing any  portion  of  the  body.  As  soon  as  the  General  Principles  are 
understood,  and  their  applicability  realized,  the  student  ceases  to  be 
overwhelmed  by  the  masses  of  detail  presented  to  him,  and  begins 
to  feel  an  interest  in  subjects  which  before  seemed  surrounded  by 
insurmountable   difficulties. 

It  has  been  the  chief  object  of  my  own  lectures,  of  which  the 
present  book  is  an  abstract,  to  emphasize  the  importance  of  these 
General  Principles,  and  the  fragmentary  and  dogmatic  character  of 
the  teaching  is  due  to  the  fact  that  my  only  intention  is  to  provide  a 
supplement  to,  not  a  substitute  for,  the  standard  textbooks. 

So  many  students  and  friends  have  begged  me  to  publish  my 
views  on  Surgery,  that  I  have  been  encouraged  to  express  them  in 
this  form.  It  would  have  been  impossible  for  me  to  do  so  in  the 
limited  time  at  my  disposal  but  for  the  invaluable  help  given  me  by 
Dr.  Boswell  of  Hartlepool,  on  whom  I  depended  for  the  correction 
and  revision  of  my  rough  proofs,  and  by  Mr.  F.  C.  Pybus,  Surgical 
Registrar  to  the  Royal  Victoria  Infirmary,  Newcastle-upon-Tyne, 
to  whom  I  am  indebted  for  the  greater  number  of  the  illustrations. 

R.  M. 

Newcastle-upon-Tyne,  November,   1910, 


Digitized  by  tine  Internet  Archive 

in  2010  witii  funding  from 

Open  Knowledge  Commons  (for  the  Medical  Heritage  Library  project) 


http://www.archive.org/details/introductiontosuOOmori 


CONTENTS. 

PAGES 

Inflammation       -------         1-18 

Results    of    inflammation — Signs    of    inflammation — Terminations   of 
inflammation — Suppuration. 


Bacteria 

Erysipelas — Gonorrhoea. 


19-32 


Ulcers     .  .  -  - 

Causes — •X'arieties — -Historv — Treatment. 


32-4-2 


Gangrene  ....---      42-53 

Causes — Line  of  Demarcation — Treatment — Gangrene  from  frostbite 
— Gangrene  from  ligature  of  arteries  or  embolism — Senile  gangrene 
— Diabetic  gangrene. 


Syphilis,  Tubercle,  .and  Malignant  Disease    -  -  -     53-102 

Ulcers — Tumours — Hodgkin's  disease — Fibrosis — Sarcomata  of  bones — 
Septic  infection — Syphilis — Diagnosis  of  chancre — Secondary  syphilis 
— Tertiary  syphilis  —  Congenital  syphilis  —  Tuberculosis  —  Cancer — ■ 
Sarcomata. 


Hemophilia 


103 


Wounds  -  -  -  - 

Aseptic  wounds — Accidental  wounds. 


I04-III 


Abdominal  and  Pelvic  Viscera  .  .  -  -  111-141 

The    hollow    viscera — Inversions    and    torsions — Strangulation — Idio- 
pathic dilatation — Some  functions  of  the  omentum. 


Indications  for  Operation 

Haemorrhage — Sepsis — To  remove  a  focus  of  disease. 


142-149 


X-RAYS 


150 


A/V 

Introduction     to     Siirjs'erv, 


^ 


INFLAMMATION. 

INFLAMMATION  is  no  longer  regarded  as  a  disease,  but  as  a 
"■  series  of  vital  changes  which  occur  in  the  tissues  in  response 
to  irritation  "  [Thomson  and  Miles.)  The  causes  are  predisposing 
and  exciting. 

Predisposing  Causes  arc — (i)  Local;    (2)  General.  .      " 

1.  Of  Local  predisposing  causes,  defective  circulation  is  the 
chief.  As  instances  of  this,  varicose  veins  an^  arterial  disease  are  to 
be  specially  remembered.  Both  diminish  tissue  resistance.  Nerve 
lesions  less  commonly  have  the  same  effect.  Traumatism  is  also  a 
predisposing  factor.  A  previous  attack  of  inflammation  in  the  same 
part  diminishes  its  vitality,  and  predisposes  to  further  attacks.-' 

2.  General  predisposing  causes  are  such  as  lower  the  bodily 
resistance.  Malnutrition,  old  age,  heart  and  kidney  disease,  diabetes, 
and  alcoholism  are  the  most  important. 

The  known  Exciting  Causes  of  inflammation  are  :— 

1.  Traumatic  :  mechanical,  chemical,  electrical,  .v-ray,  thermal 
(heat  and  cold),  etc.,  stimuli. 

2.  Microhic  infection. 

The  first  may  be  thought  of  as  implying  a  physiological,  the 
second  a  pathological  process. 

Physiological  Inflammation. — In  the  physiological  variety  the 
amount  of  reaction  is  chiefly  determined  by  the  quantity  of  the 
causative  stimulus,  in  the  pathological  mainly  by  its  quality. 

PhYsiological  inflammation  (healing)  ends  when  stasis  (destruc- 
tion) begins. 

Repair. — In  a  clean  incised  skin  wound  there  is  only  sufficient 
inflammation  to  aid  repair,  but  there  are  : — 

I.  Oozing  and  coagulation  of  blood  on  the  surface  of  a  fine  layer 
of  bruised  and  dead  tissue. 


2  INFLAMMATION 

2.  Underneath  this,  capillary  buds  develop,  and  form  capillary 
loops,  surroimded  by  round  cells  (granulation). 

3.  The  capillary  loops  of  one  side  join  similar  loops  on  the  opposite 
side,  and  the  round  cells  become  spindle-shaped  (fibroblasts). 

4.  The  surface  is  covered  by  new  epidermis  derived  from  the 
rete  ]\Ialpighii. 

5.  Formation  of  fibrous  tissue  (scar). 

The  cells  of  which  the  granulation  tissue  is  coniposed,  do  their 
best  to  reproduce  the  tissue  from  which  they  spring.  Epithelium, 
fibrous  tissue,  and  bone  are  reproduced  to  perfection.  Liver  cells 
and  kidney  cells  are  not  infrequently  replaced  by  new  liver  or  kidney 
cells.  Hair  and  nails  grow  only  from  remnants  of  their  roots.  Muscle, 
tendon,  brain,  and  spinal  cord  cannot  be  reproduced,  they  are  replaced 
by  scar  tissue. 

That  which  occurs  in  a  wound  healing  by  "  first  intention  " 
is  typical  of  healing  in  every  other  uncomplicated  wound.  Without 
sepsis,  granulations  form  ;  no  pus,  only  more  or  less  fibrous  tissue, 
according  to  the  size  of  the  gap  to  be  repaired. 

Pathological  Inflammation. — All  pathological  inflammations  are 
the  result  of  infection  by  microbes,  and  are  characterized  by  these 
phenomena. 

The  first  minute  change  observable  in  the  damaged  tissue  is 
occasionally  a  transient  contraction  of  the  smaller  blood-vessels. 

The  next  is  invariably  dilatation  of  the  blood-vessels,  and 
increased  vigour  of  the  circulation  within  them. 

Then  follow  gradual  slowing  of  the  circulation,  oscillation  of  the 
blood  in  the  vessels,  and  finally — 

Stasis  and  thrombosis. 

While  retardation  of  the  local  circulation  is  proceeding,  examine 
the  contents  of  a  blood-vessel  :  they  will  be  seen  to  divide  into  a 
central  current  of  red  colour,  in  which  movement  is  the  more  rapid, 
and  a  peripheral  current,  lighter  in  colour  and  moving  less  quickly. 

The  central  consists  chiefly  of  red  corpuscles  ;  the  peripheral  of 
liquor  sanguinis  and  leucocytes. 

When  stasis  is  complete  the  red  corpuscles  cohere,  and  form 
a  bright  central  axis. 

Tlic  leucocytes  tend  to  attach  themselves  to  the  vessel  walls. 
"  Diapedesis "  follows  adhesion  of  the  leucocytes.  They  crawl 
through  the  vessel  wall  by  means  of  amoeboid  movement,  and 
escape. 

In  a  short  time  the  connective  tissue  surrounding  the  smaller 
blood-vessels  is  crowded  with  leucocytes,  and  distended  by  fluid 
exudate,  which,  when  confined,  causes  swelling.  When  discharging 
into  a  cavity  it  implies  the  outpouring  of  a  serous,  sero-fibrinous,  or 


INFLAMMATION  3 

hcemorrhagic  or  purulent  fluid.  When  it  finds  its  way  to  the  surface 
it  causes  a  corresponding  discharge,  or  a  croupous  exudate,  which 
may  coagulate  into  a  so-called  "  false  membrane."  The  leucocytes 
are  joined  for  purposes  of  defence  by  "  free  cells,"  always  present  in 
greater  or  less  number  in  the  connective  tissue  spaces.  Both  are 
described  as  "  microphages."  A  third  large  cell  derived  from  the 
connective  tissue  elements  is  called  a  "  macrophage." 

Results   of   Inflammation. 

At  any  stage  the  above-outlined  processes  may  become  arrested. 
Before  thrombosis  has  occurred,  the  exudate  and  cells  can  disappear, 
the  circulation  become  normal,  and  the  tissues  return  to  their  original 
healthy  condition. 

1.  Resolution. — 

After  the  occurrence  of  thrombosis  there  must  be  more  or  less 
tissue  destruction,  and  this  results  in — ■ 

2.  TJie  forniation  of  fibrous  tissue  ; 

3.  Sloughing  ;    or 

4.  Gangrene. 

The   Signs   of   Inflammation. 

The  signs  of  inflammation  are — (i)  Local;    (2)  General. 

I.  The    Local    clinical    signs  of  inflammation  are — • 
Redness, 
Swelling, 
Heat, 
Pain,  and 

Loss  of  function.     [Plate  I.) 
Redness  is  the  result  of  hypersemia.      Except  in  the  most  acute 
inflammation,   it   may   be    invisible  if   the   inflamed  part  is    deeply 
situated.'     Enlargement  of   the  surface  veins  may  then  suggest  deep 
hyperjemia. 

Swelling. — Though  the  swelling  usually  comcides  with  the  in- 
flamed area,  this  is  not  invariable.  Thus,  an  inflamed  scalp  pro- 
duces oedema  of  the  eyelids  ;  an  inflamed  palm,  swelling  on  the 
dorsum  of  the  hand  ;  inflammation  of  the  lower  abdominal  wall, 
oedema  of  the  scrotum,   etc. 

Such  swelling   follows  the    path  of  least   resistance,  and  these 
transferred  swellings  may  be  of  considerable  diagnostic   importance. 
On  the  chest,  for  instance,  or  the  abdominal  wall,  on  the  scalp,  or 
surrounding  a  long  bone,  they  suggest  a  deep-seated  suppuration. 
Heat  results  from  increased  blood  supply. 


4  SIGNS     OF 

It  is  an  invaluable  clinical  sign,  for  it  denotes  active  and  progres- 
sive change.  For  example,  if  a  swollen  joint  is  hot,  it  requires  rest. 
If  it  is  cold,  there  is  no  need  for  such  care. 


Fig.  I. — DiAGRAji  TO  Illustrate  Referred  Pain  in  Intestinal  I,ESio>i, 


and  also  sunerficial  tenderness  and  muscular  rigidity.  The  dotted  arrows  and  lines  indicate  the  probable 
course  of  the  impulse  through  the  posterior  root  ganglion.  The  black  arrows  indicate  alternative  route 
through  the  sninal  cord.  {I'.N.R.)  Posterior  nerve  root.  (.S.C.)  Spinal  cord.  (Sy.C.)  Sympathetic  cord. 
(A.G.)  -Vbdominal  ganglia.  (B.V.)  Blood-vessel.  (I.N.)  Intercostal  nerve.  {.l/.)^JIesentery.  (/.)  Intes- 
tine.    (M.R.)  Muscular  rigidity.     (C.T.)  Cutaneous  tenderness. 


Pain  results  Ircjin  tension.  It  is  increased  by  dependency,  and 
relieved  by  elevation  of  the  inflamed  part ;  and  the  more  resisting 
the  structures  in  which  it  occurs,  the  greater  the  pain. 


INFLAMMATION  5 

The  character  of  the  pain  may  give  a  hint  as  to  the  structures 
involved. 

Thus,  a  boring,  aching  pain,  worse  at  night,  suggests  bone 
iniiammation. 

Mucous  membranes   ''  smart."     Serous  membranes  ''  stab." 

A  "  sickening "  pain  suggests  testicle,  kidney,  mamma,  or 
ovary. 

Apart  from  the  consideration  of  involved  structures,  a  "  throb- 
bing "  pain  suggests  suppuration. 

Pain  may  be  "referred"  and  misleading  {Fig.  i).  The  follov.-- 
ing  are  instances  : — 

Kidney  pain  may  be  felt  in  the  testicle  ;  spinal  pain  in  the 
abdomen  ;  hip  pain  in  the  knee  ;  rectal  pain  in  the  penis  ;  eye  pain 
in  the  head  ;    intestinal  pain  at  the  umbilicus. 

The  most  tender  spot  indicates  the  position  of  greatest  mischief  . 
e.g.,  pressure  with  the  point  of  a  probe  will  demonstrate  the  best  spot 
for  an  incision  in  a  case  of  palmar  abscess  ;  and  point  pressure  with 
the  finger  may  suggest  that  inflammation  of  the  gall-bladder  or  of 
the  appendix  is  the  cause  of  an  obscure  abdominal  illness. 

Impairment  of  function  is  due  either  to  pain  or  to  mechanical 
effects,  and  may  be  the  most  important  indication  of  inflammation. 
Thus,  if  a  child  walks  lame,  or  the  movements  of  one  of  its  joints  are 
impaired,  inflammation  is  to  be  suspected. 

2.  The  General  signs  of  inflammation  comprise  the  various 
features  of  inflammatory  fever  :  A  quick  pulse ;  increased  tissue 
metabolism,  shown  by  excessive  excretion  of  urea  and  urates  ; 
general  impairment  of  all  the  organic  functions  (digestion,  secretion, 
excretion  ;    and  of  nervous,   mental,   and  muscular  adequacy). 

Terminations   of   Inflammation. 

Local. — In  all  essentials  they  are  the  same  in  each  structure  ; 
they  are  : — 

1.  Resolution. 

2.  Thickening  ;  fibrosis  in  the  soft  parts,  sclerosis  in  the  bones. 

3.  Partial  Destruction  ;  ulceration,  caries,  sloughing,  pus  forma- 
tion. 

4.  Total    Destruction  ;    gangrene,    necrosis. 

Bearing  these  facts  in  mind,  it  is  not  difficult  to  understand 
the  happenings  in  inflammation.  Thus,  in  a  boil,  the  hot,  painful, 
swollen,  red  spot  may  quickly  and  entirely  disappear  ;  or  it  may 
threaten  mischief,  and  then  subside,  leaving  a  permanent  firm 
nodule  of  fibrous  tissue  (bhnd  boil).     It  may  suppurate  and  slough 


TERMINATIONS     OF 


Fig.  2. — Areas  in  an  Advancing  Boir.. 

(t)  Central  slough.  (2)  Layer  of  piis ;  dead  leucocytes.  (3)  Dense  layer  of  partially-necrosed  tissue 
infiltrated  with  leucocytes.  (4)  Area  of  vascular  stasis  with  diapedesis.  (5)  Area  of  sloughing 
with  diapedesis.     (-6)  Area  of  acceleration.     (7)  Xorraal  tissue. 


INFLAMMATION  7 

(discharge  a  core)  in  the  centre.     Or   it   may  develop  gangrene   of 
the  entire  inflamed  area,  as  in  facial  carbuncle  {Fis;.  2.) 

An  inflamed  joint   (arthritis)  may  be  restored  to  normal  ;   ma}^ 
heal,  with  fibrous  adhesions;  suppurate;  or  may  be  entireh^  destroyed. 


Base 


Fig.  ^. — Partial  1'ibrosis. 
Stricture  near  the  base  leading  to  cvstic  dilatation. 


Fig.  3. — Fibrosis. 

Appendix  after  nine  attacks  of  inflammation.  .A. 
mere  fibrous  cord.  Xo  lumen.  Just  possible  to 
differentiate  the  coats. 


The  inflamed  vermiform  ap- 
pendix (appendicitis)  may  recover 
completely  ;  may  become  fibrosed 
{Figs.    3   and    4)   (strictures    and 
thickening) ;      may    ulcerate,    or 
slough  {Fig.  5)  ;   or  total  g-^.ngrene 
may  result  {Fig.  6). 
An    inflamed    bone     may    recover    completely  ;      may    become 
sclerosed     {Fig.    7)  ;     partially     die     (caries,     cario-necrosis,     partial 
necrosis,  Fig.   8)  ;  or  may  die  entirel}^   (total  necrosis,  Fig.  9). 

General     (Inflammatory)     Fever.— Is     classified     under     three 
heads  : — 

Acute   or   chronic   saprcnnia— ^implying  the  absorption  of  toxins 
alone  into  the  blood-stream. 

Septiccemia — involving  the  entrance  of  organisms  into  the  blood. 


TERMINATIONS     OF 


Pycrmia — or  development   of  secondaiy   foci,    carried   as  emboli 

by  the  blood-stream. 

When    septic   particles    (emboli)    reach   the    general   circulation, 

which   they    chiefly  do    as    a    consequence    of    the  .  breaking    down 

and  detachment  of  protecting 
thrombi,  a  series  of  clinical  signs 
.  and  symptoms  results  which  is 
sufficiently  characteristic  for  pur- 
poses of  diagnosis.  The  conditions 
thus  indicated  are  either  those 
of  pyaemia,  or  of  malignant  endo- 
carditis. 

P573emia,  thirty  years  ago, 
was  one  of  the  most  ordinary  of 
surgical  diseases  ;  now,  thanks  to 
the  genius  of  Lord  Lister,  it  is 
one  of  the  rarest  results  of  opera- 
tions. The  traurriatisms  generally 
associated  with  it  w^ere  compound 
fractures  and  open  operations  on 
bone  :  probably  for  the  reason 
that  the  bone  veins,  relatively  large 
and  patulous,  are  held  open  by 
the  walls  of  the  bony  canals 
through  which  they  run,  making 
absorption  easy,  while  at  the  same 
time  they  have  no  valves  to  local- 
ize  the    clotting.      Probablv,    also, 

the   unyielding  bone    forces    the    septic    inflammatory  products  into 

every  available  outlet. 


Fis;. 


Acute  Inflammation  of  the 
Appendix. 


rartial    necrosis,     rerforation   opposite  stcr- 
colilh.     The  terminal  inch  almost  gangrenou-^. 


/•■/;'.  6. — Total  Necrosis. 
ApiK-ndix  on  jilass  rod.     Complete  slough,  which  floated  out  on  evacuating  an  appendix  abscess. 


At  the  present  time  the  commonest  cause  of  pyaemia  is  suppura- 
tion in  the  middle  car.     With  or  without  an  infection  of  the  petrous 


INFLAMMATION 


Humerus.  Section  of  Tibia. 

Fig.  7. — Sclerosis.      Di.\physe.^l  Osteitis. 


10 


TERMINATIONS     OF 


Fig.  8. — Partial   Destruction. 
Caries  of  lower  end  of  femur. 


INFLAMMATION 


11 


Fig.  g. — Total  Destrl-ciion  (Necrosis).       Tibia,  Acute  Osteitis. 
Entire  separation  of  periosteum  from  diaph^-sis ;    separation  of  epiphysis. 


TERMINATIONS     OF 


bone  or  mastoid,   some    of  the  small  veins  in  connection  with  the 

tympanum  become  thrombosed,  and  the 
thrombus  infected.  The  process  extends 
either  through  the  petrosal,  or  directly 
into  the  lateral  sinus,  where  the  infected 
vessels  empty,  and  detached  portions  of 
the  infected  clot  are  conveyed  by  the 
internal  jugular  vein  into  the  general  cir- 
culation [Fig.  lo).  The  first  and  the 
smallest  of  these  clot  fragments  are 
probably  destroyed  in  the  circulating 
blood  ;  but  sooner  or  later  one  of  them 
is  arrested  in  the  lungs,  causing  throm- 
bosis (infarct)  and  suppuration  (abscess) 
at  its  seat  of  arrest.  If  the  patient 
lives  long  enough,  secondary  infection 
of  the  joints  (pyaemia)  may  be  con- 
fidently expected. 

The  next  most  common  cause  is 
perhaps  appendicitis.  Here  a  septic 
phlebitis  and  thrombosis  of  the  veins 
of  the  meso-appendix  gives  rise,  in  a 
manner    corresponding    with    that    just 

described,    to    secondary    abscesses  in   the    liver.     Then    we   should 


Fig.   10. — Pyj.mic  Emboli. 

C-1)  Vein  thrombosed.  (B)  Apica! 
portion  ot  clot,  softer  than  the 
rest.  (C)  Patent  portion  of  vein. 
(D)  Tributary. 


Chart.— Pyaemia.      I,atcral  sinns  thrombosis. 


INFLAMMATION 


13 


remember  the  connection — on  similar  lines — of  septic  infection  of 
the  haemorrhoidal  veins  with  abscesses  in  the  liver,  and  of  septic 
thrombosis  of  the  ovarian  and  uterine  veins  with  puerperal 
pyaemia. 

The  clinical  evidence  in  typical  cases  of  septic  thrombosis  is  un- 
mistakable. The  first  sign  is  a  rigor  of  unusual  severity.  This  is 
usually  accompanied  by  a  considerable  rise  in  temperature.  Very 
soon  after  the  rigor  has  passed  off,  the  patient  feels  and  looks  quite 


Fig.  12. — Py.emic  Abscess  in  the  LrxG. 

Diagram  illustrating  its  formation.     Following  infarcts,  the  result  of  emboli.     Thrombosis  of  axillarj-  vein. 

Axillary  abscess. 

well  again,   and  so  continues  {Fig.    ii)  till  the  next  attack,  which 
usually  occurs  within  twenty- four  hours.* 

Only  after  a  repetition  of  the  rigors — and  it  may  be  after  many 
days  and  many  rigors — does  any  further  sign  of  serious  illness  make 
its  appearance  ;  sooner  or  later,  secondary  abscesses  develop  in  the 
viscera  {Figs.  12  and  13),  and  if  the  patient  continues  to  live,  the 
joints  are  then  invaded.  For  several  years  I  have  had  the  belief 
impressed  upon  me  by  watching  manv  cases,  that  daily  recurring 
rigors  mean  circulatory  sepsis  arising  from  some  local  septic   focus. 


Recurring  daily  rigors  suggest  circulatory  sepsis. 


14 


TERMINATIONS     OF 


which  ought  to  be  discovered,  and  must  be  dihgently  sought  for. 
The  rigors  cannot  be  due  to  anything  but  repeated  doses  of  sepsis, 
because  they  are  at  once  arrested  if  the  circulation  in  the  cliief 
veins  leading  from  the  infected  area  can  be  stopped. 

Ligature  of    the    internal    jugular  vein  in    septic   thrombosis  of 
the  lateral  sinus  consequent  on  middle-ear  suppuration  affords  the 

best  known  illustra- 
tion of  the  importance 
of  this  knowledge. 
The  same  operation 
teaches  other  import- 
ant lessons.  The  first 
is  the  importance,  not 
sufficiently  recognized, 
of  the  primary  focus. 
It  will  be  further  em- 
connection     with 


phasized     in 

tubercle,  syphilis,  and  malignant 
disease.  The  facts  to  be  remem- 
bered are,  that  if  the  primary 
focus  can  be  cut  off  from  the 
larger  venous  trunks,  further 
septic  infection  will  be  pre- 
vented ;  that  healing  of  those 
secondarily  infected  areas  al- 
ready in  existence  can  occur ; 
and  that  recovery  may  follow 
an  apparently  desperate  illness. 
That  this  has  been  no 
chance  occurrence,  nor  peculiar 
to  exceptionally  strong  indivi- 
duals, is  proved  by  an  extended 
experience.  I  have  seen  patients 
with  both  lung  abscess  and  joint 
abscesses,  secondary  to  middle- 
ear  suppuration,  recover  after 
ligature  of  the  internal  j  ugular  vein  ;  but  have  never  seen  another 
joint  infected,  or  any  further  invasion  after  the  primary  focus  had 
been  cut  off  from  the  circulation.  The  operation  is  an  imitation 
of  nature's  cure — a  cure  which  occurs  more  often  than  is  known  to 
those  who  have  not  made  post-mortem  examinations  bearing  upon  it. 
Some  years  ago,  when  specially  interested  in  the  subject,  I  made 
examinations  on  several  patients  with  middle-ear  suppuration,  or  the 
relics  of  it,  and  who  had  died  from  other  causes.     It  was  a  surprise 


Fi'^.    13. — Portal  Py.emia. 
Gangrenous  appendix.     Emboli  via  portal  vein. 


INFLAMMATION  15 

to  me  to  find  how  often  the  lateral  sinus  had  been  obliterated  by 
old  inflammation. 

Another  important  lesson  derived  from  experienees  in  connection 
with  middle-ear  suppuration,  is  the  connection  between  circulatory 
sepsis  and  inflammation  in  joints.  It  seems  probable  that  the 
accepted  explanation  as  to  the  joint  changes  resulting  from  embolic 
infection  is  the  correct  one.  It  is  certain  that  "  pyaemia"  may  cause 
changes  in  the  joints,  varying  from  the  mildest  arthritis  to  the  most 
destructive  form  of  joint  inflammation,  and  that  the  terminations  may 
resemble  those  of  any  of  the  long-named  and  ill-understood  inflam- 
matory joint  diseases,  such  as  rheumatoid  arthritis,  osteo-arthritis, 
chronic  rheumatism,  etc. 

Recent  investigators  have,  in  some  instances,  shown  the  close 
connection  of  these  conditions  with  sepsis,  and  the  possibility  that 
many  of  them  arise  in  this  way  has  been  conjectured. 

Surgical  experience  suggests  that  they  all  arise  from  a  primary 
septic  focus  ;  that  they  are  all  embolic  ;  and  that  treatment  should 
be  first  directed  to  the  discovery  of,  and  action  against,  the 
primary  focus. 

Three  forms  of  acute  multiple  arthritis  have  been  differentiated, 
and  are  well  known  and  described.  Their  distinctions  and  differences 
are  fully  accentuated  ;  but  a  fair  comparison  shows  that  the  resem- 
blance each  bears  to  the  other  is  more  marked  than  the  differences, 
and  that  in  all  essentials,  their  pathology — except  in  reference  to  the 
attacking  organism — is  the  same. 

They  are  due  to  acute  rhcuniatisni  (rheumatic  fever),  gonorrhceal 
rhcmnaiism  (gonorrhceal  arthritis),  and  pycBuiia. 

All  have  a  primary  focus  from  which  they  originate.  Its 
favourite  site  is,  for  rheumatic  fever,  the  tonsils  ;  for  gonorrhceal 
arthritis,  the  urethra  ;  and  for  pyjemia,  the  bones.  In  each,  the 
primary  focus  may  be  relatively  insignificant.  In  all,  the  infective 
organism  is  a  coccus,  with  the  common  tendency  to  run  into  clumps. 
(Is  this  the  explanation  of  embolic  infection  ?)  In  all,  the  larger 
joints  are  the  most  likely  to  be  attacked.  All  of  them  may  infect 
the  serous  membranes  and  heart  ;  or  lungs  ;  or  eye. 

In  rheumatism  the  heart  and  serous  membranes  are  frequently 
infected  ;   in  gonorrhoea  and  pyjemia  they  are  rarely  invaded. 

In  rheumatism  and  gonorrhoea  the  lungs  are  seldom  infarcted  ; 
but  in  pyaemia  they  frequently  are. 

In  rheumatism  and  pysemia  the  eye  is  seldom  involved  ;  but  in 
gonorrhoea  the  iris  is  frequently,  and  the  conjunctiva  not  seldom, 
attacked. 

The  skin  is  apt  to  be  affected,  and  erythematous  or  purpuric 
rashes  are  common  to  all. 


16  INFLx\MMATION 

The  fibrous  tissues  frequently  present  fibrous  nodules  in  rheu- 
matism ;  and  a  favourite  site  is  behind  the  elbow.  Gonorrhoea 
frequently  aftects  the  fibrous  tissues  with  a  diffuse  inflammatory 
thickening,  a  favourite  site  being  the  plantar  fascia,  and  also  the 
neighbourhood  of  the  insertion  of  the  tendo  Achillis.  Pyaemia  not 
infrequently  causes  large  abscesses  in  connection  with  the  deep  fascia, 
especially  of  the  limbs. 

Acute  rheumatic  arthritis  is  transient,  seldom  lasting  more  than 
three  weeks  ;  is  influenced  favourably  by  salicylates  ;  very  rarely 
terminates  in  suppuration ;  and  seldom  leaves  permanent  damage. 
Gonorrhoeal  arthritis  lasts  indefinitely  ;  and  is  uninfluenced  by 
salicylates  ;  suppuration  often  threatens  ;  it  may  appear  to  be 
imminent,  but  is  actually  infrequent  ;  and  a  crippling,  painful, 
permanent  stiffness  frequently  results.*  Shreds  in  the  urine  may 
be  the  only  evidence  of  the  primary  infection.  Pysemic  arthritis — 
unlike  rheumatic  or  gonorrhceal  arthritis — is  seldom  acutely  painful  ; 
often  almost  painless  ;  nearly  always  terminates  in  suppuration  ; 
and  unless  treated  early,  is  likely  to  result  in  ankylosis. 

A  first  attack  of  acute  rheumatic  arthritis  is  rare  in  patients  over 
twenty  years  of  age  ;  gonorrhoeal  and  pyfemic  arthritis  are  unusual 
before  that  age. 

Acute  Inflammation,  so  far  as  is  now  known,  is  always  caused 
by  infection  with  a  g}^enic  organism. (^CaJCi^  Q;i|  \  '\ 

In  a  healthy  person  these  organisms  have  a  difficulty  in 
establishing  a  footing.  In  a  debilitated  subject,  however,  or  amongst 
injured  tissues,  a  slight  infection  may  prove  serious. 

Chronic  inflammation  has  for  its  two  best-known  causes  the 
organisms  of  tubercle  and  syphihs. 

Conditions  between  the  two,  neither  acute  '  nor  chronic,  are 
generally  the  result  of  an  attenuated  pyogenic  organism,  or  of  a 
mixed  infection. 

The  most  acute  infections  are  generally  conveyed  from  or 
through  the  skin,  the  less  acute  through  the  blood-stream. 

It  is  increasingly  possible  to  successfully  guess  the  infecting 
organism  by  a  number  of  clinical  signs,  which,  however,  have  been 
as  yet  insufficiently  worked  out.  The  staphylococcus  p3^ogenes 
aureus  may  be  expected  in  localized  inflammations,  such  as  boils, 
carbuncles,  abscess,  and  septic  osteitis  ;  and  the  pus  in  such  instances 
is  yellow  and  creamy,  with  a  mawkish  odour.     The  streptococci,  by 


*  Always  suspect  gonorrhoea  as  the  cause  of  an  acute  arthritis  which  has  resisted 
salicylates,  in  which  the  skin  covering  the  joint  is  red  and  ccdematous,  and  especially 
one  accompanied  by  iritis. 


SUPPURATION  17 

their  tendency  to  cause  a  spreading  inflammation,  probably  extending 
to  the  lymphatics  (red  streaks  above  the  wound  indicate  this),  and 
to  the  lymphatic  glands  or  the  blood-stream,  with  a  pus  which  is  sero- 
fibrinous and  without  odour.  The  tubercle  bacillus,  from  the  chronic 
nature  of  the  inflammation  it  causes,  by  its  tendency  to  affect  the 
lymphatic  glands,  the  joints,  and  bones,  and  by  its  curdy  pus.  The 
bacillus  coli,  from  its  proximity  to  the  abdominal  viscera,  and  its 
fsecal-smelling  pus.  The  typhoid  bacillus,  from  its  tendency  to  cause 
inflammation  of  the  ribs,  or  thyroid  gland,  or  gall-bladder.  The 
pneumococcus,  as  causing  in  little  girls  an  otherwise  unaccountable 
peritonitis  with  abundant  pus  formation. 

To  ascribe  inflammation,  the  cause  of  which  is  at  present  un- 
known, to  traumatism,  rheumatism,  or  gout,  is  at  times  convenient. 
We  should  recognize  that  we  only  use  these  terms  in  this  connection 
in  order  to  cloak  our  ignorance. 

Suppuration. 

An  acute  inflammation  which  has  lasted  more  than  four  days, 
almost  certainly  terminates  in  suppuration,  of  which  two  common 
types  may  be  recognized  : — (i)  Localized, — abscess  ;  (2)  Diffuse, — 
cellulitis. 

I.  Abscess. — The  cause  may  be  a  direct  infection,  e.g.  through 
the  skin  ;  through  ducts  (mammary  abscess  is  an  instance) ;  through 
lymphatics  into  glands  ;  or  by  the  blood-stream  into  intertial  organs. 

Round  the  area  of  infection  there  is  a  large  collection  of  cells, 
which  form  a  protective  barrier,  and  attack  the  invading  organisms. 

At  the  centre  of  infection  the  accumulation  of  bacterial  toxins 
causes  tissue  death,  and  kills  the  cells  ;  while  the  exudate  is 
liquefied  by  ferments  set  free  from  dead  leucocytes,  the  whole 
product  forming  pus. 

Round  the  pus  is  a  dense  wall  of  cells  and  condensed  tissue, 
causing  tension  within.  The  larger  blood-vessels  surrounding  the 
inflamed  area  are  thrombosed  {Fig.  14). 

The  pus  burrows  in  the  direction  of  least  resistance.  Pointing 
and  escaping,  it  carries  with  it  invading  organisms.  When  the  pus 
escapes,  the  tissues  should  produce  healthy  granulations,  which  heal 
up  the  abscess  cavity. 

Sinus. — If  anything,  such  as  a  foreign  body  or  a  piece  of 
dead  tissue,  prevents  the  healing,  a  tubular  ulcer  (sinus)  results 
(Fig-    ^5,B). 

Fistula. — The  pus  may  escape  through  more  than  one  opening, 
and  if  one  of  these  is  into  a  canal  lined  by  mucous  membrane,  while 


18 


SUPPURATION 


the  other  is  through  the  skin,  the  resulting  tubular  ulcer  is  called  a 
fistula  (Fistula  in  ano  {Fig.  15,  .4),  salivary  fistula,  etc.). 

The  local  signs  of  an  abscess,  in  addition  to  those  common  to  all 
inflammations  are,  oedema  of  its  surface-covering,  and  fluctuation  of 
the  centre  of  the  localized  inflamed  area,  with  throbbing  pain. 

2.  Cellulitis.  • —  Infection  occurs  through  the  skin,  often  by  a 
trifling  wound  or  prick,  and  spreads  through  the  cellular  tissue  spaces 
and  lymphatics.  Most  mischief  may  consequently  result  at  some 
distance  from  the  point  of  infection  (e.g.  a  prick  on  the  finger  may 
result  in  an  arm  or  axillary  abscess).     Pus  infiltrates  the  meshes  of 


Fig.  14. — Areas  in  Acute  Abscess. 

(I)  Collection  of  pus.  (2)  Layer  of  necrosed  tissue  full  of  organisms  and  leucocytes.  (^)  Tissue  wiih. 
vascular  stasis  and  diapedesis.  (4)  Tissue  with  vascular  retardation  and  diapedcsis.  (5)  Tissue 
with  vascular  acceleration.     (6)  Normal  tissue. 


the  cellular  tissue,  and  by  disturbi  the  vascular  supply,  causes 
death  of  fasciae,  tendons,  and  overlying  skin,  escaping  finally  by 
many  openings. 

The  local  signs  of  cellulitis  a'-  a  diffuse,  boggy,  dusky,  tender 
swelling  of  the  skin,  recl_lyniphatic  streaks,  and  enlarged  tender 
lymphatic  glands  above  the  seat  of  infection. 

The  general  symptoms  of  pus  formation  are  :  a  rigor  at  the 
commencement,  followed  by  fever  and  leucocytosis. 

In  the  diffuse  variety,  the  constitutional  disturbance  may  be  so 
severe  as  to  cause  death  from  septiccemia  a  few  hours  after  the  signs 


BACTERIA 


19 


of  local  infection  have  been  observed.  It  is  this  variety,  moreover, 
which  is  responsible  for  the  not  rare  occurrence  of  secondary  hccmor- 
rhage,  through  erosion  of  blood-vessels. 

BACTERIA. 

Sepsis,  in  surgical  language,  means  infection  by  pyogenic 
organisms. 

Asepsis  is  the  term  applied  to  conditions  in  which  bacteria  are 
absent. 

Sterilization,  to  processes  for  killing  bacteria  by  heat. 

Antiseptic  is  the  term  which  applies  to  the  destruction  or  inhibi- 
tion of  bacteria  by  chemicals. 


Fig.  15. — Lower  End  of  Rectum. 

)  Fistula  in  ano.     (B)  Sinus  (blind  external  fistula),     (i)  Anal  canal.     (2)  Internal  sphincter  ani. 
(3)   External  sphincter  ani. 


Bacteria. — {Plate  II.) — Three  divisions  are  recognized  : — 

1.  Cocci. — Small  spherical  organisms,  in  pairs  ;  diplococci,  in 
chains  ;   streptococci,   in  clumpj  ;    staphylococci,   etc. 

2.  Bacilli,  or  rods. 

3.  Spirilla. — Spiral  rods.  Of  these,  spiroch?etes  are  the  most 
important. 

They  may  be  reproduced  by  division  or  by  sporing. 

Conditions  of  Growth. — They  require  food — protcid  and  carbo- 
hydrate— and  certain  salts.  An  alkaline  medium  favours  growth. 
They  also  require  moisture  ;  and  all  dehydrating  agents,  such  as 
sugar,  salt,  and  alcohol,  stop  their  growth.  Hence  the  employment 
of  these  agents  as  preservatives.  They  do  not  grow  in  pure  water  ; 
but  may  live  for  a  long  time  in  it.     Some  require  oxygen  (aerobic 


20  BACTERIA 

bacilli).  Others  cannot  live  in  it  (anaerobic).  The  great  majority 
can  live  either  with  or  without  it,  and  are  called  facultative 
anaerobes. 

The  temperature  of  the  human  body  is  that  best  suited  to 
bacteria.  Boiling  kills  all  of  them,  and  their  spores.  Cold  makes 
them  inactive.     Sunlight  is  inimical  to  them. 

Microbes  are,  in  a  sense,  man's  constant  companions.  In  the  air, 
they  are  carried  b}^  dust  particles  ;  tap-water  contains  them  in  abund- 
ance ;  the  skin  ;  unpurified  clothing  ;  the  soil  ;  exposed  surfaces  ; 
may  all  be  counted  upon  to  supply  contributions. 

Bacteria  which  only  live  on  dead  matter  are  known  as  sapro- 
phytes ;   those  that  grow  in  living  tissues  as  parasites. 

If  bacteria  are  regarded  as  the  seed,  and  the  body  the  soil  on 
which  they  grow,  many  difficulties  in  the  way  of  understanding 
their  action  will  disappear.  With  an  active  and  plentiful  crop  of 
bacteria,  and  tissues  well  prepared  to  receive  them,  a  virulent  attack 
of  disease  will  follow.  With  the  reverse  conditions,  a  small  or  no 
visible  effect  will  be  produced  by  the  introduction  of  micro-organisms 
to  the  body. 

When  they  gain  an  entrance  into  the  body  they  may  remain 
localized  in  the  neighbourhood  of  their  point  of  entrance,  or 
become  distributed  to  other  parts.  The  organisms  of  tubercle,  for 
example,  may  be  localized  as  cold  abscess,  or  distributed  to  joints, 
viscera,  bones,  or  skin. 

Settled  in  their  chosen  site,  they  commence  the  manufacture  of 
toxins,  which  produce  poisonous  effects,  locally  and  generally.  The 
local  effects  are  generally  cell-destruction,  and  all  of  those  changes 
included  in  the  term  "inflammation."  The  general  effects  of  absorp- 
tion of  the  toxins  of  the  pyogenic  organisms  are  those  described  as 
acute  and  chronic   sapraemia,  and  inflammatory  fever. 

Organisms  seldom,  if  ever,  multiply  in  the  blood-stream  of 
human  beings. 

In  the  body,  their  death  may  be  brought  about  by  accumulation 
of  their  own  toxins,  as  well  as  by  other  agencies  to  be  specified. 

Outside  of  the  body,  they  and  their  spores  may  be  killed  by 
exposure  to  dry  heat  of  170°  C.  for  ^h  hours  ;  by  boiling  water  in 
5  minutes  (some  spores  require  ih  hours)  ;  by  steam  at  100°  C.  in 
15  minutes  (some  spores  require  i^-  hours)  ;  or  by  germicides,  such 
as  carbolic  acid,  perchloride,  biniodide,  and  cyanide  of  mercury. 

Certain  substances  called  antiseptics,  such  as  boracic  acid  and 
weak  solutions  of  carbolic  acid,  or  mercury  perchloride,  prevent  the 
growth  of  organisms  (inhibit). 

Permanent  Microbic  Infection.  —  An  infection  by  organisms 
may,  and  frequently  does,  continue  as  a  life-long  possession.     Their 


BACTERIA  21 

imprisonment  in  the  body  may,  under  ordinary  conditions,  prevent 
them  from  working  mischief  ;  but  it  is  possible  for  them  to  assert 
themselves  from  time  to  time  during  the  whole  course  of  a  long  life. 
The  following  case  of  permanent  bone  infection,  commencing 
with  osteitis  of  the  tibia  at  the  age  of  15,  to  be  followed  by  what  was 
treated  as  chronic  rheumatism  for  fifteen  years,  and  culminating  in 
acute  osteitis  of  the  humerus  at  the  age  of  47,  well  illustrates 
this  fact. 

Case  i. — T.  D.,  aged  47,  a  miner,  was  admitted  to  the  Royal  Mctoria 
Infirmary  for  swelling  of  his  left  arm.  Eight  weeks  ago  he  had  pain  in  the 
lower  part  of  his  arm,  which  later  became  almost  unbearable.  A  swelling 
appeared.  This  was  incised,  and  pus  was  evacuated,  leaving  a  sinus  on  the 
outer  side  of  his  arm.  For  the  last  fifteen  years  he  had  been  treated  for 
rheumatism  of  the  arm.  He  had  osteitis  of  leg  (right),  when  15  years  of 
age.  There  was  a  long  typical  bone  scar  over  the  front  of  the  tibia.  On 
admission,  the  patient  was  pale  and  ill.  Temperature  102°  F.  ;  pulse  104. 
The  lower  half  of  left  arm  was  swollen  and  cedematous,  and  there  was 
a  sinus  on  the  outer  side  with  much  purulent  discharge.  Leucocytosis, 
25,000. 

Operation. — Nov.  12,  1907.  A  free  incision  was  made  over  the  diseased 
area,  and  the  bone  was  fractured  during  the  manipulations.  The  wound 
was  packed  with  gauze.  The  arm  continued  to  be  painful,  and  the  fever 
remained. 

Operation. — Nov.  20,  1907.  Amputation  at  shoulder-joint.  The 
upper  half  of  the  humerus  was  brittle  from  inflammation.  The  shoulder- 
joint  was  infected,  and  the  joint  surfaces  were  covered  by  granulations. 
Section  showed  a  diftuse  osteitis  of  both  upper  and  lower  fragments  of  the 
humerus.     Recovery. 

Another  fact  to  be  remembered  is,  that  occasionally  micro- 
organisms show  a  marked  predilection  for  certain  tissues  ;  for 
example,  in  some  patients,  the  skin  ;  in  others,  glands  ;  bones  ;  or 
joints  alone,  are  attacked. 

Leucocytosis. — Normal  human  blood  has  an  average  of  7,500 
leucocytes  per  cubic  millimetre  ;  above  12,000  may  be  regarded  as 
abnormal  {Plate  III,  Figs.  A  and  B)  ;  and  j^,ooo  as  implying  an 
exceptionally  high  degree  of  leucocytosis.  After  the  invasion  of  the 
body  by  bacteria,  the  number  of  leucocytes  in  the  blood  is  increased. 
In  all  surgical  infective  diseases  leucocytosis  may  be  expected,  and 
this  knowledge  may  be  a  valuable  aid  in  diagnosis  or  prognosis. 
After  the  first  rise  in  temperature,  leucocytosis  should  be  present, 
increasing  as  the  infection  progresses,  diminishing  steadily  as  it 
recedes,   and  increasing  again  if  suppuration  follows. 

If  the  number  of  granular  polymorphonuclear  neutrophile  leuco- 
cytes (for  it  is  wdth  this  variety  chiefly  that  surgeons  are  concerned) 
is  increased,  bacterial  infection  is  suggested  as  the  cause  of  illness. 


22  BACTERIA 

As  a  watch-dog  for  the  formation  of  pus,  leucocytosis  may  be  invalu- 
able ;  the  absence  of  it  in  infections  where  it  might  have  been  expected 
suggests  a  serious  condition,  and  is  strong  confirmation  of  a  prognosis 
already  grave  from  other  signs. 

Defences  of   the  body  against  micro-organisms  : — 

1.  The  healthy  unbroken  skin  externally,  and  the  mucous  mem- 
branes internally,  are  the  most  powerful  defences  of  the  body  against 
the  attacks  of  micro-organisms. 

2.  Mucus  secretions,  in  addition  to  their  mechanical  protection, 
probably  act  as  antiseptics. 

3.  When  either  skin  or  mucous  membrane  is  damaged,  microbes 
may  at  once  gain  admittance  ;  but  they  may  also  be  immediately 
washed  out  of  the  wound  by  the  escaping  blood,  which,  moreover, 
b}^  its  clotting  in  and  around  the  wound,  imposes  an  obstacle  to 
their  further  entrance,  and  thus  affords  protection  where  most 
needed. 

4.  When  an  effectual  entrance  has  taken  place,  the  inflammatory 
reaction  which  follows,  results  in  the  production  of  a  temporary 
barrier,  which  may  stop  invading  organisms  from  reaching  the 
circulating  blood. 

5.  The  temporary  barrier  of  condensed  inflammatory  tissue 
thus  interposed  may  become  organized  (fibrosis  or  sclerosis),  and 
imprison  the  organisms  indefinitely  (permanent  infection). 

6.  Should  the  organisms,  however,  in  defiance  of  these  defen- 
sive processes,  succeed  in  reaching  the  blood-stream,  they  are 
combatted  : — 

{a).  By  the  production  of  antibacterial  substances  in  the  blood 
serum. 

{h).  By  agglutination  of  the  bacteria  in  clumps. 

(c).  By  phagocytosis. 

a.  Antitoxins. — Certain  organisms,  such  as  those  of  tetanus  and 
diphtheria,  kill  by  the  production  of  toxins,  which  toxins  alone  are 
sufficient  to  produce  the  same  disease  as  the  organisms  themselves, 
and  with  fatal  results.  Moreover,  a  dose  of  the  toxin,  just  as  well  as 
of  the  microbes,  introduced  into  the  blood  of  an  animal,  causes  the 
formation  of  an  antidote.  The  antidote,  or  "'antitoxin,''''  in  the 
serum  of  an  animal  so  treated,  may  be  used  as  an  aid  to  treatment  ; 
but  it  docs  not  kill  microbes.  These  are  destroyed  by  a  different 
method. 

Vacci7ies. — If  dead  microbes  are  injected  into  the  circulation, 
they  prevent,  or  inhibit,  the  growth  of  similar  germs  in  the  blood. 
Such  blood  may  be  directly  poisonous  to  the  special  micro- 
organisms, or   cripple   their   activities.     The  bactericidal   substances 


BACTERIA  23 

arc  diminished  in  blood  taken  from  the  body,  and  so  treated  ; 
and  are,  on  the  other  hand,  increased  in  the  circulating  blood, 
which  proves  that  these  substances  are  generated  in  the  body  by 
this  stimulus. 

h.  AggliUination. — Blood  may  cripple  the  bacteria  by  agglu- 
tinating them  together  in  clumps.  (Practical  use  of  this  know- 
ledge has  been  made  in  connection  with  the  diagnosis  of  typhoid 
fever.) 

c.  Phagocytosis. — The  most  important  defence  of  the  body  is 
that  offered  by  the  phagocytes  (white  cells).  They  try  to  devour 
and  destroy  all  intruders,  and  upon  their  success  or  failure  the  result 
depends.  The  phagocytes,  however,  require  to  circulate  in  a  serum 
which  will  tempt  them  to  attack  the  enemy. 

Opsonic  Index. — Calculation  of  the  opsonic  index  is  based  upon 
this  knowledge.  {Plate  IV.)  A  certain  number  of  bacteria  are 
exposed  to  the  action  of  a  certain  corresponding  number  of 
phagocytes  for  the  same  period  of  time,  in  (i)  normal  serum,  in 
(2)  serum  from  the  patient.  Slides  are  made  and  stained,  the 
number  of  microbes  in  each  phagocyte  is  counted,  and  an  average 
obtained  of  the  number  ingested  in  each  case.  The  ratio  of 
these  numbers — the  opsonic  index — shows  to  what  extent  the 
patient's  blood  is  more  or  less  active  in  attacking  the  bacteria  than 
is  normal  blood. 

The  opsonic  index  is  normally  raised  by  the  injection  of  dead 
microbes  into  the  body  ;  and  the  treatment  by  vaccines  is  based 
on  this  principle. 

Microbes  are  seldom  free  in  the  blood.  In  the  body,  they  are 
usually  imprisoned  by  a  wall  of  infiammator}^  tissue,  awaiting  an 
opportunity  for  mischief.  Under  such  circumstances,  dead  microbes 
injected  into  healthy  tissues  stimulate  the  phagocytes  to  attack 
these  intruders,  and  to  disturb  the  peace  of  the  quiescent  focus. 

Vaccine  treatment  has  so  far  been  most  successful  in  the  more 
chronic  localized  infections  ;  and  it  has  to  be  remembered  that  each 
inoculation  only  affects  the  special  microbe  for  which  it  has  been 
made  ;  indeed,  so  specialized  are  microbic  infections  that,  to  get 
the  best  results,  it  is  necessary  to  use  the  patient's  own  micro- 
organisms. 

The  Iodine  Glycogen  Reaction. — In  most  surgical  infections, 
some  of  the  polynuclear  leucocvtes  will  be  stained  brown  with  a 
mixture  of  watery  solution  of  iodine  and  iodide  of  potassium. 

Temperature  and  pulse  are,  for  clinical  purposes,  graphically 
recorded  on  charts,  which  show  at  a  glance  the  correspondence  of 
these  important  signs  with  the  other  features  of  a  case,  and  with  the 
course  it  is  taking  {Figs.  16  to  25). 


24 


BACTERIA 


Fig.   1 6. — Chart. 
J.  B.,  age  38.       Inguinal  hernia.     Radical  cure. 


TIME 

M    eIm    EJM    eIm     eIm     e 

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T.  W.,  age  40,  male.     Simple  fracture  of  tibia  and  fibula. 


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Fi?.   18. — Chart. 
D.  S.,  age  25,  male.     Cellulitis.     Note  pus  retention. 


BACTERIA 


25 


TIME 

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Fig.   19. — Chart. 
jr.  R.,  age  23,  female.     Pelvic  cellulitis.     Recoven-. 


TIME 

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F;?.   20. — Chart. 
R.  H.,  age  43,  male.     Diffuse  cellulitis  follo'wing  wound  of  hand. 


26 


BACTERIA 


TIME 

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J.  G.,  age  38,  male.     Fractured  spine.     Bladder  sepsis. 


Fig.    22. — ClMRT. 
J.  G.,  age  37,  male.     Conipoiind  fracture  of  foot.     Gangrene.     Amputation. 


BACTERIA 


27 


TIME    |m      e|m      e|m      e|m       eIm       EiM      E  [m      E 

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C.  B.,  age  74,  male.     Senile  gangrene.     Aseptic.   Spontaneous  separation  of  toe.     Calcareous  arteries.     Pain, 
tingling,  and  numbness  for  10  years. 


Fig.   24. — Ch.\rt. 
J.  I..,  age  67,  female.     Senile  gangrene.     Septic.     Arrest  of  sepsis  by  amputation  through  thigh.     Recovery. 


Fig.  25. — Chart. 
R.  R.,  age  53,  male.     Diabetic  gangrene.     Septic. 


28 


ERYSIPELAS 


Erysipelas. 

Erysipelas  is  due  to  streptococcic  infection  of  the  skin  or  of  a 
mucous  membrane,  through  a  wound,  which  may  be  very  minute. 

It  spreads  peripherally,  often  spasmodically.  At  its  outer  edge 
the  lymphatics  are  filled  with  streptococci,  which  may  also  be  obtained 
from  superficial  blebs. 

The  first  sjmiptoms  are  shivering,  headache,  general  malaise, 
and  often  vomiting  {Fig.  26.)  The  temperature  rises;  the  pulse 
is  quick  ;  the  tongue  foul,  and  often  dry  ;  the  urine  scanty,  and 
often  albuminous  ;  the  gastro-intestinal  functions  are  disturbed  ;  and 
there  is  frequently  delirium. 


DAVOr  1   /w 
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TIME    |M       C 

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Fig.  26. — Chart. 
E.   L.,  aged  21,  female.     Facial  erysipelas  following  septic  scratch. 


Round  the  infected  point  the  skin  is  red,  glossy,  swollen,  and 
hot  ;  and  a  burning  pain  is  present.  The  exudate,  in  addition  to 
showing  itself  as  swelling,  often  appears  in  serous  blebs  on  the  surface 
of  the  red  area.  The  swollen  edge,  where  the  disease  is  progressing, 
is  specially  tender  to  the  touch,  and  its  spread  may  be  noted  by 
observation  of  the  tender  area.  The  lymphatics,  when  superficial, 
may  be  seen  as  red  lines  in  the  skin  ;  and,  when  deeper,  can  be  felt  as 
tender  cords.  The  glands  into  which  the  infected  area  drains  are 
swollen  and  tender. 

{It  will  be  observed  that  the  above  description  is  simply  that  of 
an  acute  spreading  inflammation  of  the  skin  with  inflammatory  fever. 
It  illustrates  how  a  special  disease,  in  this  case  erysipelas,  may  be 
thought  of  in  terms  of  general  principles  alone.) 


GONORRHCEA  29 

The  disease  has  an  incubation  period  of  from  one  to  two  days  ; 
and  a  duration  of  from  one  to  two  weeks.  Recovery  is  usual  ;  but 
death  may  result  from  toxaemia,  meningitis,  or  from  blood  infection. 
Chronic  oedema  may  also  result  from  repeated  attacks. 

Varieties  : — 

Facial  erysipelas. 

Erysipelas  iieonatonuji  (around  the  umbilicus  of  newly-born 
babies).     Always  fatal. 

Phlegmonous  erysipelas,  or  cellulo-cutaneous  erysipelas,  or  diffuse 
cellulitis.  (Here  diffuse  suppuration  or  abscess  formation  is  likely  to 
occur  in  the  infected  cellular  tissue.) 

Angina  Ludovici. — (Diffuse  cellulitis  occurring  in  the  neck  ; 
secondary  to  mouth  infection.) 

Paranietritis. — Chiefly  affecting  the  cellular  tissue  of  the  broad 
ligaments  of  the  uterus,  and  secondary  to  laceration  and  infection  of 
the  uterine  cervix. 

Treatment. 

The  whole  of  the  red  area  should  be  painted  twice  daily  with 
tincture  of  iodine,  and  round  this,  at  a  distance  of  one  inch,  a  ring  of 
iodine  liniment  should  be  painted  every  morning.  The  painted 
surface  should  then  be  covered  with  cotton  wool.  Five  grains  of 
calomel  at  night,  followed  by  a  seidlitz  powder  in  the  morning,  should 
be  administered  every  other  day,  and  the  patient  allowed  to  drink 
abundantly  of  water. 

GONORRHCEA. 

Gonorrhoea  is  an  inflammation  due  to  the  gonococcus  which 
primarily  affects  the  urethra  in  males,  the  urethra  and  cervix  uteri 
in  females,  the  vulva  in  little  girls,  and  the  conjunctiva  in  infants. 

Modes  of  Infection. — Ordinarily,  by  coitus  ;  extraordinariH% 
during  birth  (the  eyes  of  babies)  ;  and  by  infected  clothing  and  towels 
(in  children). 

Pathology. — Gonococci  may  be  free  in  the  pus,  or  contained  in 
leucocytes.     (See  Plate  II,  Fig.  B.) 

.  They  may  spread  superficially,  involving  the  posterior  urethra, 
urethral  gland  ducts,  prostatic  ducts,  vas,  epididymis,  vesiculae, 
ureters  and  kidneys,  and  the  kidney  pelvis  ;  or,  deeply  into  the  sub- 
mucous layer  of  the  urethra  (the  cause  of  stricture)  ;  or  into  the 
corpus  spongiosum  (the  cause  of  chordee). 

Signs. — Three  to  five  days  after  the  infection,  swelling,  redness, 
a  burning  sensation,  and  heat  are  noticeable  at  the  meatus.     Then 


30 


GONORRHCEA 


M 


follow    purulent    discharge,    pain    on    micturition,    swelling    of    the 
prepuce,  and  often  chordee. 

Progress. — After  two  to  four  weeks,  the 
symptoms  abate  if  the  disease  is  limited  to 
the  anterior  urethra. 

Treat:\ient. 

The  main  object  in  treatment,  for  males, 
is,  if  possible,  to  limit  the  disease  to  the 
anterior  urethra,  i.e.  the  portion  of  the  urethra 
in  front  of  the  compressor  urethrae  muscle. 
The  chief  indications  are,  rest  in  bed,  cleanli- 
ness, and  free  drain- 
age. The  latter  are 
secured  by  frequent 
antiseptic  ablutions 
and  changes  of  anti- 
septic absorbent 
cotton  dressings. 
Abortive  treatment, 
such  as  the  use  of 
strong  injections 
before  forty  -  eight 
hours,  has  been 
successful,  but  only 
rarely.  After  the 
acute  symptoms 
have  subsided,  the 
careful  use  of  anti- 
septic injections, 
especially  of  those 
containing  silver,  is 
of  value.  An  abun- 
dant supply  of  fluid, 

as    barley-water,  fj?.  27.— go.vorrhceai,  infection. 

milk  and  soda-water 
in   equal  parts,   dis- 
tilled     water,     pure 
drinking    water,     or 
other  diluents  to  in- 
crease   the    quantity  and  to  diminish  the  irritating  contents  of  the 
urine,  are  important  aids.     In  the  later  stages,  the  internal  administra- 
tion of  santal  oil  in  steadily  increasing  doses  up  to  30  minims  three 
times  daily,  if  well  tolerated  by  the  stomach,  may  be  of  great  service. 


The  arrows  indicate  the  direction  of  superficial  spread.     Deep 
spread — i.  Tissue  of  urethra.     2.   Corpus  spongiosum. 


{A)  Prepuce. 

(B)  Clans  penis. 

(C)  Urethra. 

(D)  Cowper's  eland. 
(/■")    Prostatic  urethra. 


(F)  Prostate. 

(G)  Seminal  vesicle. 
(H)  Vas  deferens. 
(/)    Epididymis. 


(K)  Testicle. 
(/,)    Bladder. 
(.U)  Ureter. 
(N)  Kidney. 


GONORRHCEA 


31 


If  the  inflammation  has  extended  to  the  posterior  urethra,  as 
indicated  by  a  frequent  and  urgent  desire  to  micturate,  recovery- 
requires  some  months,  and  a  satisfactory  treatment  can  only  be  based 
upon  the  findings  discoverable  by  skilled  urethroscopic  examination. 
The  condition  called  gleet  depends  upon  a  great  variety  of  lesions 
which  can  only  be  discovered  by  the  same  skilled  methods,  without 
which  any  treatment  is  unlikely  to  be  satisfactory. 

In  women,  the  urethral  infection  is  seldom  severe  or  lasting,  and 
requires  nothing  more  than  rest,  cleanliness,  and  the  internal  use  of 
diluents. 


Fig.   jS.^Goxorrhceal   Infection. 

The  arrows  indicate  the  direction  :    (A\  Vulva.     (B)  Vagina.     (C)  Cervix  uteri.     (D)   Uterus.     (E)  Urethra. 

(f )  Bladder.     (G)   Ureter. 


A  uterine  cervical  infection  should  be  treated  actively  by  the 
introduction  of  a  probe  carrying  a  solution  of  nitrate  of  silver,  grs.  x 
to  the  ounce,  three  times  a  week,  and  daily  packing  of  the  upper 
vagina  with  iodoform-formalin-gauze,  till  all  evidence  of  disease  has 
disappeared. 

Complications. — These  are  local  and  general. 

Local. — In  men,  balanitis  and  inflammation  of  prepuce,  para- 
phimosis, infection  of  Cowper's  glands,  prostate,  vesiculae  seminales, 
vasa    deferentia,    epididymis,    bladder,    ureters    and    kidneys,    pelvic 


32 


GONORRHCEA 


peritoneum,  lacimne.  and  lymphatics  of  urethra  (causing  abscess  or 
suppurating  glands),  and  of  sub-mucous  tissue  (causing  stricture) 
{Fig.  27). 


In  women,  to  infection  of 
Bartholinian  glands,  uterus, 
Fallopian  tubes,  pelvic  peri- 
toneum, and  rectum  {Figs. 
28  and  29). 

In  both  sexes,  sterility 
frequently  results  ;  in  males, 
from  fibrosis  of  the  epididy- 
mis ;  and  in  women,  from 
fibrosis  of  the  Fallopian 
tubes. 

General.  —  Gonorrhoeal 
ophthalmia  (the  greatest 
single  cause  of  blindness), 
gonorrhoeal  pyaemia,  arth- 
ritis, bursitis,  and  endo- 
carditis. 


Fig.  29. — Spread    of    Gonorrhceal    Infection. 

The  arrows  show  the  direction:   (/I)  Vulva.     (B)  Bartholin's  gland.     (C)  Vagina.     (D)  Cervix.     (£)  Uterus. 
(F)  Fallopian  tube.     (G)  Opening  into  pelvic  peritoneum.     (H)  Ovar}-.     (/)  Pelvic  cellular  tissue. 


Ulcers. 

Ulcers  and  gangrene  must  be  considered  in  connection  with 
inflammation  {Fig  30). 

The  cause  of  ulcer  is  a  localized  defective  blood  circulation,  and 
of  gangrene  its  complete  arrest. 

Cause.— The  defective  blood-supply  causing  ulceration  is  nearly 
always  due  to  inflammation ;  consequently,  ordinary  ulcers  (not 
cancerous  and  other  special  varieties)  are  to  be  regarded  as  the  result 


ULCERS 


33 


of  infection  by  pyogenic  microbes,  or  by  the  organisms  of  tubercle 
or  syphilis. 

Other  conditions  predispose  to  ulceration,  and  they  may  be 
either  General  or  Local. 

General  Predisposing  Causes  are  :  debility,  from  any  cause  ; 
anaemia  ;   heart  disease  ;    Brighfs  disease  ;   diabetes  ;   scurvy,  etc. 


Fi'i.  30. — Debility  (Varicose)   Ui.cer. 
Xote  the  position  in  lov.  er  part  of  leg. 


Local  Predisposing  Causes  are  :  traumatism  (especially  con- 
tinuous pressure)  ;  and  diseases  of  arteries,  veins,  or  nerves. 

Varieties. — The  following  varieties  of  ulcer  are  described  in 
text-books  :  simple  healing  ulcer  ;  exuberant  ;  oedematous  ;  callous  ; 
varicose  ;  irritable  ;  perforating  ;  inflammatory ;  sloughing  ;  phage- 
dfenic  ;   tuberculous  ;    venereal  ;    scorbutic,  etc. 

In  making  a  diagnosis  in  cases  of  ulcer  there  are  certain  questions 
to  be  answered.     They  concern  : — 

3 


34 


ULCERS 


The     History.      How  did  it  commence  ? 

A  varicose  ulcer  commences  frequently  with  an  irritable  patch 
of  dermatitis,  or  a  small  abrasion.  A  syphilitic  ulcer,  as  a  firm 
nodule  which  ^'  inflamed  and  broke."  Perforating  ulcer,  with  a 
corn,  etc. 


Pi!,_   31. — Syphilitic   (Gummatous)   Ulceration^  of  I.egs. 
Xote  the  position  of  ulcers  in  the  upper  part  of  legs. 


Does  anything  in  the  Condition  of  the  Patient  suggest  a  cai.       ? 
e.g.,    Scars   on   the  neck,  or   other   signs    of    tubercle.      Rema  \s    li 
old  syphilis  in  the    eyes,    nose,   mouth,    throat,    ears,    or    else^     -1  \ 
Varicose  veins.     Evidences  of  scurvy.     Signs  of  nerve  disease, 
as  aucesthesia,  etc. 

What   is    its    Locality  ?  j^ 

Debility    ulcers    choose   the    lower    third    of   the   leg    {Fig.   3 


/ 


ULCERS 


35 


Syphilitic    ulcers,    localities    where    the    blood-supply    is    normally 
least ;  namely,  the  mid-hne  of  the  body,  the  upper  third  of  the  leg, 


Fig.  32. — Tuberculous  Ulceration  of  Neck. 
Note  the  position. 


the  region  of  the  deltoid,  and  the  buttocks  {Fig.  31).  Tuberculous 
ulcers  choose  positions  where  the  vascular  supply  is  best,  such  as 
the  face,  neck  {Fig.  32),  etc. 

Is   there    more   than    one    Ulcer  ? 

e.g.,  Multiplicity   suggests    tubercle 
or  syphilis. 

The  Shape  of  the  Ulcer  ? 
A  serpiginous  shape,  or  multiple 
circular  sores,  suggest  syphilis.  An 
oval,  longer  vertically,  suggests  a 
varicose  ulcer.  A  deep,  punched  out, 
circular  sore,  a  perforating  ulcer  {Fig. 
33)'  etc. 

The    Character    of    the    surround- 
ing   Skin  ? 

Irregular,  hard,  puckered  cicatrices, 

i     .ic  te     burns      {Fig.     34).        Circular 

ar        and      pigmentation      point      to 

lis     {Fig.     35).      Depressed     scars 

^one    {Fig.    36).      Around    varicose 

;rs  the  skin  is  eczematous,  dusky,  and  pigmented.     It  is  hairy, 
tokened,  and  coarse  in  the  neighbourhood  of  callous  ulcers. 


F;?.  33. — Diagram  of  Perforating 
Ulcer. 

(.-1)  Section  of  corn.  (B)  Track. 
(C)  Perforation  of  joint  and  septic 
arthritis.     Painless  when  probed. 


36 


ULCERS 


The    Discharge  ? 

Small    in    qiiantitv,  watery,   and    foetid,   in  callous  ulcer.     Con- 
taining  tubercle   bacilli,   in   tuberculous  ulcer.     Abundant,  purulent, 


Fis:.   34. — Burn  Scar.     Showing  deformity  of  arm. 


^i?-   35- — Scars  of  Heai.kd  Gi-mmata  over  Knek  axd  1'ront  of  I,eg. 


ULCERS 


37 


Fig,  36. — A  Bone  Scar.     Note  the  depression.     The  scar  is  fixed  to  the  rib. 


and  sanious.  in  active  spread- 
ing ulcer.  Thick,  and  fcetid, 
in  syphilitic   ulcer. 

The    Edge  ? 

Thick,  firm,  whitish,  and 
elevated,  in  callous  ulcer. 
Undermined,  thin,  livid,  sur- 
rounding tags,  in  tuberculous 
ulcer  [Fig.  37).  Undermined, 
thick,  and  purple  edge,  in 
syphilitic  ulcers.  Corny,  in 
perforating  ulcers. 

The    Base  ? 

Tubercular  in  tuberculous 
ulcer.    "Wash-leather  slough" 


I.  Hcalinii  L'lccr. — (A)  Norma!  skin.  (B)  Ilcaped- 
up  eiiithelium.  (C)  Thin  ad\aneuig  ni:u;-;in  of 
epithelium.      (D)    Granulations. 


2.    Tuberculous  Ulcer. — Undermined  cd^es  with 
pcrtorations  and  tags. 


3.   GuDunalous  Ulcer. — Cleanly  punched  out.    Slough 
on  base. 

Fig.    37. — DlACKAMMATlC     SECTION'    OF    ULCERS. 

3a 


38 


ULCERS 


in   syphilitic    ulcer.     Greenish,   glazed    appearance    in    callous    ulcer. 

Pain  ? 

This   may  be  the  chief   characteristic  of  some   ulcers — irritable 
ulcers.     x\bsence  of   pain,    indeed   anaesthesia,    that    of   others,    per- 
forating  ulcers   {Fig.   38). 

Is  the  Ulcer  extending, 
healing,    or    neither  ? 

An  extending  ulcer  is 
attended  by  the  signs  of 
inflammation.  A  healing 
ulcer  is  painless  ;  it  dis- 
charges but  little  ;  the  sur- 
rounding skin  is  healthy ; 
the  edge  is  shelving  ;  and 
there  are  from  without 
inwards,  white,  blue,  and 
red  circles  of  new  epithe- 
lium extending  on  to  the 
sore  {Fig.  39),  the  base 
of  which  is  covered  with 
small  red  granulations  to 
the  level  of  the  surround- 
ing skin.  It  is  decreasing 
in  size. 


Treatment. 

The  Principles  of 
Treatment  are  simple  : 
they  comprise  an  endeavour 
to  remove  the  predisposing 
and  exciting  causes. 

Where  much  skin  has 
been  destroyed  it  may  be 
needful  to  assist  the  efforts 
of  nature  by  skin-grafting. 


Fig.  38. — Perforating  Ulcer' (Tabes  Dorsaiis). 

Bare  bone  was  discovered  with  a  probe  at  the  bottom 

of  the  ulcer.     The  introduction  of  the  probe  was  not 

felt  by  the  patient. 


The  treatment  of  ulcers  is  (i)  General,  and  (2)  Local. 

I.  General  Treatment  is  mainly  the  same  as  that  of  inflamma- 
tion, namely,  rest.  For  tuberculous  and  syphilitic  ulcers,  the  con- 
stitutional treatment  necessary  for  each  has  to  be  added.  The 
treatment  of  tuberculosis  comprises  an  endeavour  to  bring  about 
an  improvement  in  the  resisting  power  of  the  patient.  The  most 
generally    useful    of    antisyphilitic    remedies    is    to    be    found    in    a 


ULCERS 


39 


combination  of  potassium  iodide  and  bichloride  of  mercury  (potass, 
iodid.  gr.  xv,  hydrarg.  perchlor.  gr.  t.t,  dissolved  in  a  wineglassful 
of  water,  and  taken  three  times  a  day). 

2.  The  Local  Treatment  aims  at  : — 

a.  The  position  of  rest  which  most  aids  the  local  circulation. 

b.  The  application  of  moist  heat. 

c.  The  abolition  of  sepsis. 

d.  A  dressing  which  will  not  interfere  with  wound  healing. 

For  ulcers  of  the  lower  extremities,  rest  in  bed  is  specially  indi- 
cated, as  a  first  step.     It  is  not  essential  to  keep  the  legs  still  after 


Fig.  3n. — Diagram  of  Sukface  of  Healing  Ulcer. 

(i)  Red  granulating  area.     (2)   Bluish  area — thin  laj-er  of  epithelium.     (3)  White  area — sodden 

epithelium.     (4)  Normal  skin. 


active  mischief  has  subsided.  They  should  indeed,  whilst  lying,  be 
exercised  regularly  three  times  a  day — as  in  pedalling  a  bicycle — in 
order  to  stimulate  the  circulation. 

For  the  first  dressing  of  inflamed  ulcers  a  large  hot  bread  poultice, 
made  of  old  bread-crumbs  and  boracic  acid  lotion  (  5j  to  the  pint), 
renewed  every  six  hours,  cannot  be  beaten.  The  poultice  should  be 
covered  with  an  abundant  layer  of  cotton  wool,  and  its  heat  main- 
tained by  hot  bottles,  or  substitutes  for  them. 

In  a  few  days  (when  improvement  has  commenced),  or  at  once 
with  chronic  ulcers,  a  careful  attempt  should  be  made  to  disinfect 
the  ulcer  and  surrounding  skin  by  prolonged  washing  (for  not  less 


40  ULCERS 

tlian  a  quarter  of  an  hour)  with  carbolic  lotion,  of  strength  5  per  cent. 
After  this,  the  following  dressing  should  be  applied  :  next  the  ulcer  a 
portion  of  green  protective,  large  enough  to  entirely  cover  the  sore, 
but  no  more.  The  protective  must  first  be  disinfected  in  corrosive 
sublimate  lotion,  i  in  1000,  wdiich,  previous  to  its  application,  is  washed 
off  in  warm  boracic  lotion.  Over  the  protective,  a  large  thick  pad  of 
sterile  gauze,  wrung  out  of  hot  boracic  lotion.  Over  the  gauze,  a 
thick  sprinkling  of  sterile  boracic  acid  powder,  and  abundance  of 
heated  cotton  wool  (gamgee  tissue  is  most  convenient).  The  whole 
dressing  is  then  retained  with  a  bandage,  and  heat  maintained,  as 
before,  by  hot  bottles.  It  is  unnecessary,  and  hurtful,  to  disturb 
this  dressing  frequently.  If  there  is  no  discomfort,  no  discharge, 
no  bad  odour,  and  no  rise  in  temperature,  it  should  be  left  in  posi- 
tion for  a  W'Cek.  The  same  dressing,  with  a  starch  or  plaster-of-Paris 
bandage,  is  most  useful  for  patients  who  are  obliged  to  go  about 
during  treatment. 

When  all  these  conditions  cannot  be  fulfilled,  the  best  substitute 
is  Martin's  indiarubber  bandage.  It  is  a  pity  that  a  device  so 
excellent  should  be  so  little  employed.  Few  leg  ulcers  will  not  heal 
under  it,  and  many  people  with  large  ulcers  suffer  needless  pain  and 
disability  for  the  want  of  it.  It  should  be  put  on  in  the  morning, 
before  getting  out  of  bed,  wdth  no  reverses,  and  with  just  sufficient 
firmness  to  hold  on,  and  it  should  be  worn  all  da^^  There  should  be 
no  tight  feeling  or  discomfort  in  the  leg  or  foot  on  getting  up.  Over 
the  bandage,  a  long,  thick,  well-fitting  woollen  stocking  should  be 
carefully  drawn.  At  night,  after  getting  into  bed,  the  bandage  is 
taken  off.  The  leg  and  ulcer  are  thoroughly  washed  with  soap  and 
hot  water,  and  the  ulcer  is  covered  with  a  piece  of  green  protective, 
WTung  out  of  hot  boracic  lotion,  and  with  boracic  lint  similarly 
treated.  The  leg  is  then  bandaged  in  cotton-wool  for  the  night. 
All  this  dressing  is  taken  off  in  the  morning :  and  after  the  leg  has 
been  well  rubbed,  the  bandage  is  re-applied  to  the  bare  skin  and 
ulcer.  The  indiarubber  bandage  should  be  thoroughly  washed 
with  soap  and  hot  water  every  night,  and  hung  up  to  dry  till 
morning. 

The  patient  must  be  warned  that  "  boils  "  may  develop  under 
the  bandage,  but  that  they  must  be  allowed  to  constitute  no  objection 
to  its  continued  use.  He  should  also  be  cautioned  that  the  bandage 
will  be  ruined  by  the  application  of  any  grease. 

Treatment  of  Special  Ulcers. — The  healing  of  callous  ulcers 
may  be  expedited  by  painting  liquor  epispasticus  over  the  ulcer  and 
the  surrounding  skin,  previous  to  the  apphcation  of  the  poultice. 

Tuberculous  ulcers  should  be  excised  when  feasible,  otherwise 
they  should  be  curetted,  cauterized  with  pure  carbolic  acid,  and  dressed 


ULCERS 


41 


with  iodoform.  Syphilitic  ulcers  may  be  stimulated  by  a  black- 
wash  dressing,  or  their  healing  may  be  hastened  by  the  surgical 
removal  of  pieces  of  dead  tissue. 

Ideal  Treatment. — If  the  ulcer  is  not  too  large  ;  if  the  condition 
of  the  surrt)unding  tissues  is  satisfactory  ;  and  if  the  patient's  health 
be  favourable,  excision  of  the  ulcer,  followed  by  the  application  of 


F/;.   40. — Cancrum  Oris.     Acute  localiztd  infective  gangrene. 


a  graft  of  the  entire  skin  to  the  wound  resulting,  is  the  most  satis- 
factory of  all  forms  of  treatment.  Skin-grafting  on  a  more  moderate 
scale  is  occasionallv  useful. 


Acute  Infective  Localized  Gangrene. — Occupying  a  place  mid- 
way between  ulceration  and  gangrene,  there  are  a  variety  of  conditions 
— phagedai^na,  noma  {Fig.  40),  facial  carbuncle,  etc. — due  to  bacterial 


42  ULCERS 

infection  of  so  virulent  a  character,  that  the  inflammation  they  set 
up  in  the  tissues  attacked,  ends  in  local  death,  and  absorption  of  their 
virulent  toxins  not  infrequently  kills  the  patient.  The  signs  in  ah 
are  the  same.  They  are  those  of  an  inflammatory  swelling,  so  vicious 
in  its  progress,  that  indications  of  local  gangrene  are  obvious  before 
many  hours  have  passed.  The  treatment  for  all  these  conditions  is 
to  remove  the  entire  focus  of  infection  as  soon  as  this  can  possibly 
be  done. 

The  difference  between  an  ordinary  and  an  infective  gangrene 
cannot  be  observed  to  better  advantage  than  on  the  penis.  Acute 
balanitis  and  a  tight  prepuce  may  cause  sloughing  of  the  entire 
prepuce,  from  the  tension  arising  from  inflammation  and  pent-up 
secretion.  The  whole  prepuce  may  die;  hut,  the  gangrene  is  marked 
off  by  a  hne  surrounding  the  glans  penis,  and  is  limited  accordingly. 
On  the  other  hand,  acute  infective  gangrene  (phagedsena)  causes 
sloughing,  generally  localized,  of  the  prepuce  ;  but  spreads  quickly 
to  involve  the  skin  covering  the  penis,  the  scrotum,  and  the  abdominal 
wall. 

Death  of  any  part  of  the  tissues  will  follow  arrest  of  its  blood 
circulation  (this  is  the  cause  of  gangrene).  In  the  soft  tissues,  a  dead 
portion  is  called  a  slough,  the  term  gangrene  being  generally  under- 
stood as  referring  to  the  death  of  an  extremity,  or  of  a  large  part 
of  it. 

GANGRENE. 

A  rare  form  of  gangrene  is  due  to  infection  with  virulent  bacteria  ; 
and  in  its  rapid  course,  and  frequently  fatal  termination,  resembles 
the  localized  infective  gangrenes  previously  mentioned.  In  such  a 
case  following  a  wound,  possibly  one  so  trivial  as  a  prick,  the 
signs  of  a  violent,  progressive  inflammation  are  evident.  The  whole 
extremity  is  swollen  in  a  few  hours  ;  the  red  blush  of  inflammation 
changes  to  a  purple  hue ;  the  purple  becomes  patchy,  and  the  inter- 
vening skin  like  mottled  glazed  tallow.  Blebs  form  on  the  surface ; 
crackling  of  putrefactive  gases  in  the  interior  may  be  felt  by  pressing 
on  the  skin  ;  and  the  patient  dies  before  the  fourth  day  has  passed. 
In  some  of  these  cases,  a  specific  bacillus — the  bacillus  of  malignant 
oedema — has  been  found.  It  has  also  been  obtained  from  the  well- 
manured  soil  of  gardens.  The  only  useful  treatment — though 
recovery  has  seldom  follo'vved — is  high  amputation,  special  precau- 
tions being  taken  to  prevent  reinfection  of  the  wound  by  the 
infected  part  during  its  removal. 

Case  2. — The  only  case  of  recovery  I  can  recall  is  that  of  a  ])oy,  aged  8, 
who  was  admitted  to  the  Royal  Infirmary  on  May  27,  1892. 


GANGRENE  43 

He  was  admitted  for  a  C()mi)()und  fracture  of  the  radius  and  ulna 
from  being  run  over.  Mr.  \\'ardale,  then  house  surgeon,  cleansed  the 
limb ;  and  everything  ajipeared  to  be  going  well  till  the  evening  of  June  3rd. 
On  June  4th,  I  saw  the  boy.  His  arm  was  swollen  up  to  the  shoulder  ; 
there  was  a  considerable  area  of  gangrenous  skin  round  the  wound  in 
the  forearm  ;  crepitation  could  be  felt  under  the  swollen  skin  ;  and  his 
general  condition  was  very  grave.  I  at  once  amputated  the  arm  at  the 
shoulder-joint  ;  left  the  wound  quite  open  ;  and  packed  its  cavity  with 
lint  soaked  in  tincture  of  iodine. 

Next  morning,  the  boy's  condition  was  still  very  grave  ;  and  crepita- 
tions could  be  felt  under  the  skin  covering  the  chest  as  far  as  the  sternum, 
and  over  the  back  and  scapula  as  far  as  the  spine.  It  was  obvious  that 
the  gangrenous  process  had  extended  to  the  underlying  parts.  I  shall 
never  forget  the  ward  sister's  reproachful  lo(jk,  as  if  it  was  a  cruel  request, 
when  asked  that  the  boy  should  again  "  be  sent  to  the  theatre  at  once." 
I  then  proceeded  to  remove  as  much  of  the  skin  of  the  chest  and  back  as  I 
dare.  The  underlying  parts  were  crackling  with  gas,  and  of  a  dirty  green 
colour.  After  excising  the  pectoral  muscles,  the  scapula,  and  the  muscles 
connected  with  it,  4  again  packed  the  open  wound  with  strips  of  lint 
soaked  in  tincture  of  iodine. 

From  this  time  the  gangrenous  process  was  arrested,  and  the  boy 
recovered. 

The  usual  forms  of  gangrene  depend  upon  arrest  of  the 
circulation  by  more  ordinary  conditions,  and  they  have  not  the 
active  spreading  qualities  of  the  infective  gangrene  described. 

Causes. 
The  causes  are — (i)  Predisposing  and  (2)  Exciting. 

1.  Predisposing  Causes  are  :  debility  from  any  cause — old  age, 
heart  disease,  diabetes,  Brighfs  disease  ;  and  certain  disturbances 
of  the  nervous  system  (Raynaud's  disease). 

2.  Exciting  Causes  are  :  crushes,  burns,  and  scalds ;  chemicals ; 
strangulation ;  prolonged  pressure ;  injury,  or  ligature,  or  diseases, 
or  embolisms  of  the  blood-vessels. 

It  is  well  known — sometimes  not  sufficiently  remembered — that 
a  bandage  too  tightly  applied  will  produce  gangrene. 

If  a  not  too  fat  limb  were  chosen,  emptied  of  its  venous  blood  by 
elevation  and  elastic  bandaging  from  the  toes,  and  a  tourniquet  were 
then  applied  above,  suliiciently  tight  to  arrest  all  circulation  ;  the 
limb  below  the  tourniquet  would  become,  first  pale  and  shrivelled, 
then  tallowy,  then  brown,  and  finally  black,  dry,  and  mummified, 
until  it  dropped  off — dry  gangrene.     {Plate   V.) 

If  a  bandage  were  applied  tightly  to  a  similar  limb,  but  only 
sufficiently  so   to  arrest  the  venous  and  not  the  arterial  circulation,  it 


44  GANGRENE 

would  become  swollen  and  purple  below,  then  mottled,  then  red, 
purple  and  green  ;  blebs  would  develop  on  the  skin,  which,  on  separ- 
ating, would  leave  a  slimy,  soft,  stinking,  gangrenous  mass — moist 
gangrene. 

The  clinical  ditterences  are  specially  marked,  and  are  emphasized 
in  all  books  ;  the  danger  and  the  constitutional  disturbance  associated 
with  the  moist  variety  receiving  special  notice.  This  is  attributed  to 
infection  by  organisms,  and  quite  rightly  ;  but  it  should  also  be  pointed 
out,  that  this  infection  is  secondary,  and  an  avoidable  complication. 
If  the  skin  of  the  gangrenous  extremity  had  been  made  surgically 
clean,  and  a  suitable  antiseptic  dressing  had  been  applied,  it  would 
then  have  been  made  possible  for  the  fluids  to  escape  and  dry  up, 
and  for  the  limb,  affected  with  moist,  to  assume  the  condition  of 
dry,  gangrene.  The  constitutional  disturbance  usually  associated  with 
moist  gangrene  would  not  then  show  itself,  since  it  is  due  to  the 
growth  of  organisms  in  the  gangrenous  tissue,  organisms  which  have 
effected  an  entrance  through  the  damaged  skin.  This  explains 
the  difference  between  the  bed-sore  of  a  good  and  of  a  bad 
nurse.  A  bed-sore  may  be  unavoidable ;  but  the  good  nurse, 
by  careful  preparation  of  her  patient's  skin,  limits  the  mischief 
to  the  part  pressed  upon,  while  the  poor  nurse's  patient  develops 
inflammation  from  dirt  and  infection,  and  has  a  rapidly  spread- 
ing sore. 

Emboli  {Thomson  and  Miles''  Text-hook). 

"  The  Abdominal  Aorta  may  become  suddenly  occluded  at  its 
bifurcation  by  an  embolus,  the  obstruction  of  the  iliacs  and  femorals 
inducing  symmetrical  gangrene  of  both  extremities  as  high  as 
Poupart's  ligament  {Fig.  41).  When  gangrene  follows  occlusion  of 
the  external  iliac,  or  of  the  common  femoral  artery,  the  death  of 
the  hmb  extends  as  high  as  the  middle  or  upper  third  of  the  thigh 
{Fig.  42).  When  the  superficial  femoral  or  popliteal  artery  is  ob- 
structed, the  veins  remaining  pervious,  the  anastomosis  through  the 
profunda  is  sufficient  to  maintain  the  vascular  supply,  and  gangrene 
does  not  necessarily  follow.  The  rupture  of  a  popliteal  aneurysm, 
however,  by  compressing  the  vein  and  the  articular  vessels,  usually 
determines  gangrene.  When  an  embolus  becomes  impacted  at  the 
bifurcation  of  the  popliteal,  the  gangrene  which  ensues  usually 
spreads  well  up  the  leg  {Fig.  43).  When  the  axillary  artery  is 
the  seat  of  embolic  infection,  and  gangrene  ensues,  the  process 
usually  reaches  the  middle  of  the  upper  arm  {Fig.  44).  Gangrene 
following  blocking  of  the  brachial  at  its  bifurcation,  usually  ex- 
tends as  far  as  the  junction  of  the  middle  and  lower  tliirds  of  the 
forearm  "   {Fig.   42). 


GANGRENE 


45 


Evcrv  gangrene  is  due  to  arrested  circulation. 

In  infective  gangrene,  inflammation  is  the  cause  of  the  arrest, 
and  the  distinguishing  character  is  its  tendency  to  spread  independently 
of  the  chief  vascular  supply. 


Fig.  41. — Embolism  at  Bifurcation  or 
Abdojuxai.  Aorta. 


fjv.  _j2. — Embolism    of    External  Iliac  (or 

COMJIOX    FEMOR.4L)  :    AND  AT   BRACflLAL   ARTERY 
AT  BEXD   OF   ElBOW. 


There  is  no  such  thing  as  a  genuine  dry  gangrene.  Every 
ordinary  gangrene  is  originally  moist.  Whether  it  becomes  dry ;  not 
dangerous  to  life ;  and  not  spreading,  or  the  reverse,  depends  upon 
whether  it  can  be  kept  free  from  organismal  infection,  or  "  goes 
septic."     Dry  is  an  aseptic,  and  moist  a  septic,  gangrene. 


46 


GANGRENE 


The  Line  of  Demarcation.— At  the  ] unction  of  the  hving  tissue 
with  the  gangrenous  area,  a  hne  of  inflammatory  reaction  commences. 
{Plate  V.)  Along  this  hne,  granulations  form  from  the  living  part, 
and  by  phagocytic  action,  the  dead  area  in  contact  with  the  granu- 


Fi^.  43. — Embolism  at  BiFrRCATioN   of 
Popliteal  Artery. 


Pig_  4^. — Embolism  of  Axillary,  and  of  vSuper- 
FiciAL  Femoral  (or  Popliteal)  Arteries. 


lating  surface  is  eaten  away.  First,  the  skin  separates  ;  then  the 
deeper  parts,  muscles,  vessels,  and  nerves  ;  finally,  the  bone. 
Division  of  the  bone  especially  requires  a  long  time  ;  the  process 
occupies  many  weeks,  and  the  dangers  of  septic  infection  of  the 
wound,   and  septic  absorption  from  it,  arc  considerable.     The  end 


GANGRENE 


47 


result  of  such  unaided  amputation  is  not  good,  for  the  skin  dies 
sooner,  retracts  higher  than  do  the  muscles,  and  the  muscles  higher 
than  the  bone,  exactly  reversing  the  results  of  a  satisfactory- 
amputation  operation  {Fig.  45).  If  healing  is  possible,  a  conical 
stump  ensues. 


Fiq.  45. — Diagram  illustratinc  a  .Surgical  and  Gangrenous  Amputation. 

I.  Surgical    amputation.     2.  Natural   amputation,    after   seDaration   of   gangrenous    part. 
{A)  Skin.      (S)  JIuscle.      (C)   Bone. 

The   symptoms    and    signs    of    gangrene,    when    the   process    is 
complete,  are  so  plain  that  no  one  can  mistake  them.     It  is  when 


Fiq.  46. — Diabetic  Gangrene. 
Superficial,  and  starting  on  the  dorsum  of  the  foot ;    not  in  the  toes. 


48  GANGRENE 

gangrene  is  threatening  that  the  diagnosis  is  important,  and  it  is  then 
that  it  is  most  difficult.  It  is  usual  for  patients  to  have  premonitory 
s^-mptoms,  because,  in  the  majority  of  cases,  gangrene  is  only  an 
end  result ;  the  circulation  has  been  interfered  with  long  before 
its  total  arrest.  (Usually  thrombosis  in  the  diseased  vessel  deter- 
mines the  gangrene.) 

In  senile  gangrene — that  clinical  variety  due  to  atheroma  of 
the  vessels — the  patient  suffers  from  alterations  in  sensation 
of  the  foot  and  leg.  It  may  be  a  feeling  of  constant  coldness, 
or  of  burning  heat,  so  severe  as  to  drive  him  to  sleep  with  the 
affected  foot  out  of  bed  ;  or  one  of  tingling  combined  with  pain 
and  numbness.  The  first  indications  of  gangrene  are  likely  to  be 
seen  at  the  end  of  a  toe. 

In  diabetic  gangrene,  cramps  in  the  calf  of  the  leg,  so  bad 
as  to  make  the  patient  shout  and  faint,  have  often  preceded 
local  signs.  A  patch  or  patches  of  gangrene  on  the  sole  or 
other  parts  of  the  foot  {Fig.  46),  not  the  toe  ends,  suggest  diabetes 
as  a  cause. 

In  Raynaud's  disease,  many  threatening  attacks,  lasting  from 
a  few  minutes  to  hours,  have  come  and  gone  before  gangrene 
supervenes,  and  such  attacks  have  often  been  followed  by  hccmo-' 
globinuria. 

The  condition  of  the  circulation  can  be  tested  in  three  ways  : 

1.  By  examination  of  the  main  arteries  as  to  the  state  of  their 
walls  (thickening,  induration,  or  :v-rays.  Fig.  47),  and  the  strength 
of  their  pulsation. 

2.  By  testing  the  capillary  circulation.  The  rough  test,  usually 
employed,  is  to  press  all  blood  out  of  the  skin,  and  watch  the  rapidity 
of  its  return. 

3.  By  the  production  of  artificial  hypenemia.  If,  after  elevating 
the  limbs  to  empty  them  of  blood,  an  elastic  bandage  is  applied 
as  a  tourniquet  to  each,  left  on  for  a  few  minutes,  and  then 
taken  off,  the  normal  limb  will  quickly  flush  down  to  the  toes, 
the  abnormal  one  only  to  that  position  where  the  circulation 
is  active.  (This  test  may  be  employed  as  an  aid  in  the  deter- 
mination of    the   amputation  site.) 

Treatment. 

When  gangrene  is  threatened,  something  may  be  done  to  arrest 
it  ;  when  it  has  developed,  the  worst  consequences  arising  from  it 
may  be  averted.  In  every  case,  it  is  essential  to  make  the  skin 
surgically  clean  as  soon  as  the  possibility  of  gangrene  is  suspected. 
This  can  be  done  by  thorough  washing  with  soap  and  hot  water. 


GANGRENE 


49 


followed  by  careful  sponging  with  i-iooo  corrosive  sublimate  and 
spirit  lotion,  dusting  with  boracic  powder,  and  an  abundant  wool 
dressing.  Between  fingers  and  toes,  strips  of  dry  boracic  lint  should 
be  laid,   to  keep  the  skin  between  them  separated   and   dry.     The 


Fis.  47- — -Skiagram  of  I,eg  from  a  case  of  Senile  Gangrene. 
Note  the  calcareous  arteries. 


limb  should  be  placed  in  a  slightly  elevated  position  to  favour  the 
return  of  venous  blood,  and  for  the  same  purpose  it  should  be  rubbed 
upwards,  from  above  the  dressing,  for  a  few  minutes  several  times 

4 


50 


GANGRENE 


daily.  Hot-water  bottles,  when  used  with  care,  are  useful  aids. 
When  gangrene  threatens  the  foot  and  leg,  as  it  usually  does,  the 
patient  must  stay  in  bed,  and  not  be  allowed  to  hang  the  leg  down 
for  any  purpose  whatever.     A  dose  of  opium,  sufficient  to  secure 


Fiij.  48. — Gangrene  of  Left  I,eg. 
Due  to  embolism  in  popliteal  artery.     (See  Temperature  chart.) 

relief  from  pain  and  afford  rest,  should  not  be  withheld,  and  ought  to 
be  given  every  night,  if  required.  Nutritious  food,  and  aperients, 
or  a  daily  enema,  complete  the  general  directions. 


Fig.  49. — Chart. 

S.  E.  I,.,  age  29,  female.     Gangrene.     Embolism  of  popliteal  artery  and  thrombosis  of  all  veins  14  days 

after  parturition. 

When  gangrene  has  developed,  if  the  gangrenous  part  can  be 
kept  dry,  two  courses  are  open  :  to  leave  the  separation  to  nature, 
or  to  amputate  {Figs.  48  and  49).  (Traumatic  gangrene,  including 
burns,  scalds,  etc.,  only  demands  amputation  above  the  injured  part.) 


GANGRENE 


51 


Gangrene  from  Frostbite. — The  ordinary  preventive  treatment 
requires  modification  in  the  case  of  frostbite  with  threatened  gan- 
grene. The  most  successful  practice  appears  to  be,  first  to  rub  the 
affected  part  with  snow  in  a  cold  room,  and  only  by  degrees  to  allow 
the  patient  to  go  into  a  warmer  atmosphere  and  use  warmer  clothing. 
If  gangrene  occurs,  the  extremity  should  be  kept  aseptic,  and  watched 
till  the  limit  of  the  gangrene  is  clearly  seen.  Amputation  can  be 
performed  immediately  above  this. 


Transversalis  colli 
\ 


Supra- scapula 


Subclavian 


Supra-scapular 


Long 
thoracic 

Internal 
mammery 


Subscapular 


Fig.  50. — Anastomosis  after  I^igatcre  of  the  third  part  of  Axillary  Artery. 


Gangrene  following  Ligature  of  Arteries  or  Embolism. — The 

application  of  a  ligature  to  any  vessel  {Figs.  50  and  51)  large  enough 
to  make  gangrene  a  possibility  {Figs.  41-44),  demands  that  the  skin  of 
the  extremity  should  be  made  surgically  clean,  in  the  manner 
previously  described,  and  no  careful  surgeon  would,  except  in 
emergency,  so  operate  in  the  presence  of  a  septic  area  in  the  part 
below.  The  quotation,  previously  offered  (page  44),  suggests  the 
average  result  of  ligature  or  embolism  of  the  large  arteries  when 
gangrene  follows  ;  but  so  much  depends  on  the  many  factors  con- 
cerned in  the  blood  circulation,  that  it  is  impossible  to  make  any 
definite  rule  as  to  amputation,  except  that  it  may  turn  out  to  be 
false  economy  to  try  to  save  too  much.  Probably  the  hyperaemia 
test  offers  the  most  satisfactory  measurement,  for  it  would  be  safe 
to  amputate  where  this  showed  the  blood  circulation  to  be  active. 


52 


GANGRENE 


Senile  Gangrene. — Obstinate  sores  in  connection  with  injuries 
or  corns,  or  ingrowing  toe-nails,  when  the  patients  are  elderly,  require 
the  greatest  attention,  as  they  often  form  the  starting-point  of  senile 
gangrene.  If  the  gangrene  is  limited  to  a  toe  or  toes,  it  is  my  practice 
to  advise  waiting,  and  careful  dressing.  The  slightest  operative 
assistance  to  separation  of  the  gangrenous  part  must  be  long 
delayed,  and  a  useful   rule  is  to  do   as  little  as  possible.     So  soon 


Common  femoral 

Internal  circumflex 

Deep  femoral 

ExiBrnal_ 
circumflex 


Superficial 
femoral 


Muscular, 
branches 


Muscular 

Sup.  ext.  articular 
Inf.  ext.  articular. 

Sup .  fibular 

Recurrent  anterior 
tibial 


Perforating 
branches 


AnastomoiJca  magna 

Popliteal  artery 

Sup.  internal 
articular 


Inferior  internal 
articular 


Fig.  51. — Anastomosis  after  I^igature  of  the  Superficial  Femoral  Artery. 

as  gangrene  has  extended  on  to  the  foot,  nothing  is  to  be  gained 
by  waiting,  and  the  patient's  condition  deteriorates  from  pain,  from 
loss  of  rest,  exercise,  and  appetite,  whilst  the  dangers  of  septic 
infection  are  very  real.  My  rule,  then,  is  to  advise  amputation  at 
or  above  the  knee. 

Diabetic  Gangrene. — The  progncjsis  here  is  worse  than  in  senile 
gangrene;  but  early  amputation  above  the  knee,  along  with  proper 


•^  \ 


SYPHILIS,   TUBERCLE,   MALIGNANT   DISEASE     53 

attention  to  the  general  eondition,   is   followed  bv  reeovery  in  the 
majorit}'  of  cases. 

The  best  form  of  amputatit)n  to  employ  in  these  cases  is  one  on 
the  principle  of  the  old  circular  method.  This  entails  less  interfer- 
ence with  the  circulation  in  the  stump  than  any  other. 


SYPHILIS,    TUBERCLE,    AND    MALIGNANT    DISEASE. 

Three  of  the  most  common  surgical  diseases,  tubercle,  syphilis, 
and  malignant  disease,  resemble  each  other  in  so  many  respects  that 
it  will  be  helpful  to  consider  them  together,  before  entering  on  the 
details  of  each  separately. 

For  two  of  them — syphilis  and  tubercle — the  responsible  organ- 
ism has  been  discovered.  It  is  still  being  searched  for  in  respect  to 
cancer  and  sarcoma. 

All  of  these  diseases  commence  locally,  and  spread  mainly  by  the 
lymphatics. 

The  primary  lesion  in  each  may  either  take  the  form  of  a 
tumour,  or  that  of  an  ulcer.  Thus,  in  cancer  of  the  tongue,  ulcer 
is  common  while  tumour  is  rare  ;  in  the  breast,  ulcer  is  rare 
(Paget"s  nipple),  while  tumour  is  common. 

In  tubercle,  the  primary  lesion  is  frequently  so  trifling  as  to  pass 
unobserved. 

In  syphilis,  it  may  be  so  insignificant  as  to  attract  no  attention. 

In  malignant  disease,  it  is  usually  a  most  important  feature. 

The  skin  and  genito-urinary  organs  are  the  favourite  sites  in  all. 

Syphilis  remains  localized  for  so  short  a  time  that  the  generalized 
manifestations  of  it  have  rarely,  if  ever,  been  prevented  by  the  earliest 
excision  of  the  primary  lesion.  In  malignant  disease  early  excision 
of  the  primar\'  lesion  alone  offers  a  chance.  In  tubercle  it  does  not 
often  fail. 

The  importance  of  the  primary  focus  in  all  these  diseases  is  not 
yet  sufficiently  recognized.  If  the  primary  focus  in  cancer  is 
removed,  secondary  growths  will,  in  a  certain  percentage  of  cases, 
disappear.  This  has  occurred  in  chorion  epithelioma,  when,  after 
hysterectonw,  a  secondary  growth  in  the  lung  gave  no  further 
trouble.  It  is  also  proved  by  the  occasionally  successful  results 
of  old-fashioned  operations  for  cancer,  in  which  only  the  primary 
growth  was  excised,  for  it  is  now  accepted  knowledge  that,  in  the 
great  majority  of  these  cases,  the  nearest  lymphatic  glands  are 
early  infected. 

All  of  them  infect  and  cause  enlargement  of  the  lymphatic  glands. 
These  seem  to  offer  little  or  no  resistance  to  the  diffusion  of  syphilis  ; 


54 


SYPHILIS,     TUBERCLE,     AND 


considerable  resistance  to  the  dissemination  of  tubercle  ;  and,  for  a 
long  time,  they  stop  the  advance  of  malignant  disease.  Therefore, 
syphilis  is  always  disseminated,  tubercle  frequently,  malignant  dis- 
ease rarely. 

The    glandular   enlargement  in   syphilis  is  general  ;    in  tubercle 


52.— Patient  with  Primary  Cancer  of  the  Pancreas  and  Secondary 
Growths  dotted  over  the  body  in  the  skin. 


limited ;  and  in  malignant  disease  localized.  Following  syphilitic 
infection,  all  the  local  glands  swell  and  feel  like  almonds.  Shortly 
after,  all  the  glands  in  the  body  participate.  Syphilitic  glands  never 
suppurate.  Following  tuberculous  infection,  the  local  lymphatic 
glands  swell,  one  at  a  time,  feel  like  a  string  of  small  potatoes,  tpnd 


MALIGNANT     DISEASE 


Ot) 


to  form  large  tumours,  and  frequently  suppurate.  Following 
cancerous  infection,  the  local  glands  enlarge  (those  nearest  the  point 
of  infection  tirst),  they  grow  into  hard  fixed  tumours,  and  seldom 
suppurate  except  in  the  neck. 

Dissemination   always  occurs  before   three   months   in   syphilis, 


Fig.  53. — Back  view  of  the  same  Patient  as  Fig.  52. 


and  on  the  skin  it  appears  usualh'  as  a  roseolous  eruption.  The  dis- 
semination of  tubercle  is  rare,  and  occurs  chieify  in  the  viscera  of 
the  head,  chest,  and  abdomen.  General  dissemination  of  cancer 
is  rarer  still.  When  it  occurs  in  the  skin  all  over  the  body,  the 
eruption,  on  superficial  examination,  may  be  mistaken  for  that  of 
syphilis    {Figs.   52   and   53).     On   the  other  hand,    dissemination  of 


56  SYPHILIS,     TUBERCLE,     AND 

sarcoma  is  to  be  expected  ;  and  when  it  attacks  the  lungs  and  pleura, 
the  SMiiptoms  and  signs  of  tuberculous  disease  are  closely  simulated. 

In  each,  manj''  of  the  conditions  described  as  characteristic  of  the 
disease  are  the  result  of  septic  infection  of  the  primaty  focus.  This 
ma}-  be  a  serious  complication  in  all  of  them. 

S}^hili5  confers  complete  immunit}' ;  tubercle  partial  immu- 
mty  :   malignant  disease,  probabh-  no  immunity  at  all. 

Ulcer. — It  is  generaU\'  possible  to  offer  a  correct  diagnosis  as  to 
whether  an  ulcer  is  due  to  tubercle,  or  to  cancer,  or  to  s\^philis.  The 
age,  appearance,  and  sex  of  the  patient ;  the  history'  of  how  the 
condition  commenced,  and  its  site  ;  are  of  an  importance  next  to 
the  physical  signs.  ^^ 

Tubercle  is  most  common  in  the  }-oung  ;  s^'philis  in  the  middle- 
aged  :   and  cancer  in  the  old. 

Tuberculous  subjects  look  thin  and  anaemic,  or  fat  and  pasty 
(delicate)  ;  the  syphihtic  look  "  dr^-."'  with  a  mudd}^  anaemia  ;  and 
the  cancerous,  florid  and  robust. 

Tubercle  and  cancer  affect  both  sexes  equalty  ;  syphilis  mainh^ 
the  male. 

A  tuberculous  ulcer  usually  commences  as  a  small  sore,  which 
has  gradually  de5tro3'ed  its  site  (destruction  in  excess  of  growth)  ; 
the  cancerous  ulcer,  as  an  irritable  crack  around  which  a  tumour  has 
developed  (growth  in  excess  of  destruction)  ;  the  syphilitic  ulcer,  as 
a  tumour  which  has  broken  down  (an  ulcerating  tumour). 

Tubercle  and  cancer  choose  sites  furnished  with  the  best  vascular 
supplv  :  svphilis  with  the  worst. 

Mistakes  will  become  less  frequent  with  improved  diagnosis  ;  but 
are  sometimes,  as  yet,  unavoidable.     The  following  are  examples  : — 

Ulcers. — I  have  excised  an  ulcer  of  the  lower  lip,  and  along 
with  it  the  enlarged  submaxillary  and  submental  glands  of  an  elderly 
man,  for  "  epithehoma."  ^licroscopical  examination  of  the  growth 
and  of  the  glands  proved  tubercle. 

I  excised  the  tongue  of  a  stout,  florid  man,  between  50  and  60, 
for  an  "  epithelioma,"  w^hich  proved  to  be  tubercle.  He  was  quite 
well  ten  \'ears  later. 

I  excised  the  uterus  of  a  patient  for  ''  carcinoma  of  the  cervix." 
This  was  also  a  case  of  tuberculous  disease. 

Most  students  have  seen,  or  will  see  in  the  infirmary  clinics, 
chancres  of  the  lip  or  tongue  sent  in  as  "  epitheliomata."  I  treated 
one  girl  of  26  and  a  man  of  28  with  mercury  and  iodide,  for  a 
"chancre  of  the  lip."  They  both  died  of  cancer  of  the  lip  and 
neck  respectively  within  one  year. 


MALIGNANT     DISEASE  57 

I  have  observed  cases  of  "  cancer  of  the  cervix  uteri  "  cured  by  a 
course  of  iodide  and  mercury.  They  were  syphihtic  sores,  and  either 
had,  or  developed  later,  signs  typical  of  syphilis. 

A  large  number  of  "  cancers  "  of  the  face  have  been  cured 
by  mercury  and  iodide  ;  and  as  large  a  number  of  cancers  of 
the  tongue  and  of  the  penis  have  had  their  chance  of  cure 
lost  through  delay  in  operating  whilst  the  same  means  were  being 
"fairly  tried." 

Tumours. — The  chronic  inliammatory  swellings  produced  by 
tubercle  and  syphilis  have  not  infrequently  been  mistaken  for 
malignant  disease,  and  vice  versa. 

JMany  bowel  "  tumours,"  due  to  tubercle,  especially  of  the  caecum, 
have  been  excised  under  the  belief  that  they  were  malignant. 

I  operated  on  a  case  of  "  cancer  of  the  pylorus,"  and  found  the 
disease  too  far  advanced  for  anything  but  the  palliative  operation  of 
gastro-enterostomy.  To  confirm  the  diagnosis,  I  removed  a  gland. 
It  only  contained  tubercle.  The  microscopical  diagnosis  was  con- 
firmed by  the  permanent  recovery  of  the  patient,  and  the  disappear- 
ance of  the  tumour. 

A  middle-aged  woman  had  "  cancer  of  the  liver  and  ascites,  with 
hard  lumps  in  the  omentum,  and  jaundice."  Examination  revealed 
typical  tertiary  sj-^philitic  ulceration  over  the  left  shoulder.  Mercury 
and  iodide  cured  her. 

A  man,  aged  t,8,  had  three  attacks  of  acute  intestinal  obstruction 
in  eighteen  months.  After  the  last  of  these  I  opened  his  abdomen, 
and  found  a  "  fixed  inoperable  malignant  growth  "  in  his  sigmoid 
flexure.  His  doctor,  who  was  present  at  the  operation,  mentioned 
that  he  had  treated  him  for  syphilis  seven  years  before.  Since  a 
mercurial  course  he  has  had  no  further  attack,  and  fifteen  years 
after  is  well.  Fortunately,  I  refrained  from  making  a  permanent 
colostomy  opening,  because  I  thought  it  would  be  soon  enough  for 
that  when  the  obstruction  recurred. 

A  middle-aged  man  had  an  "  aneurysm  of  the  thoracic  aorta 
eroding  his  sternum."  The  "  aneurvsm  "  disappeared  after  six 
weeks  of  mercury  and  iodide. 

I  excised  a  large  thyroid  for  "  malignant  growth  "  from  a  woman 
of  middle-age.     The  microscope  revealed  tubercle. 

In  another  case,  I  made  a  diagnosis  of  malignant  thyroid,  and 
offered  a  hopeless  prognosis.  Six  months  afterwards  an  abscess 
opened,  and  the  pus  was  tuberculous.  The  patient  was  alive  three 
years  later. 

A  stout,  healthy-looking  lady  was  operated  upon  bv  one  of  my 
colleagues  at  my  request  for  a  "  typical  scirrhus  of  the  breast." 
A   macroscopic    section    confirmed    our    diagnosis.     The    pathologist 


58  SYPHILIS,     TUBERCLE,     AND 

and  ourselves  required  more  than  one  series  of  microscopic  sections 
to  satisfy  us  that  we  were  all  wrong.     The  "  tumour  "  was  tubercle. 

A  '"  tumour  "  of  a  bone  may  be  due  to  either. 

I  once  saw  a  leg  amputated  at  the  hip-joint  for  "  sarcoma  "  at 
the  lower  end  of  the  femur.     This  was  a  syphilitic  gumma. 

A  patient  had  his  leg  amputated  at  the  upper  part  of  the  thigh 
for  a  "  sarcoma  "  of  the  lower  end.  Sixteen  months  later  a  "  second- 
ary growth  "  appeared  in  the  upper  end  of  the  humerus  of  the  opposite 
side.  This  was  cured  with  iodide  and  mercury,  and  the  patient  is 
alive  and  well  fifteen  years  later. 

A  patient  was  advised  amputation  at  the  hip  for  a  "  sarcoma  " 
of  the  upper  end  of  the  femur.  The  advice  was  not  accepted.  Twelve 
months  later  a  tuberculous  abscess  was  opened,  and  recovery  followed. 

A  patient  was  operated  on  for  "  tubercle  "  of  the  upper  end  of 
the  humerus.  Profuse  haemorrhage  followed  the  incision,  and  a 
fungating  mahgnant  growth  appeared  through  it  a  few  days  later. 

Even  a  skiUed  pathologist  with  his  microscope  may  make 
mistakes. 

A  man  aged  35  had  his  right  testicle  removed  for  a  "  round- 
celled  sarcoma."  Nine  months  later  he  "  developed  a  secondary 
growth  in  his  brain."  This  serious  brain  lesion  disappeared  after  a 
course  of  mercury  and  iodide  ;  nearly  twenty  years  later  he  is  well. 

I  was  once  asked  to  look  down  a  microscope  and  offer  a  diagnosis. 
I  felt  no  doubt  that  the  section  of  skin  revealed  bore  a  typical  epithe- 
lioma.    It  was  a  nodule  of  leprosy,  and  a  favourite  "  catch." 

A  young  married  man  had  his  left  testicle  excised  for  "  tubercle." 
The  diagnosis  was  confirmed  by  the  microscope  (no  tubercle  bacilli 
were  found).  One  year  later,  his  right  testicle  swelled  as  the  other 
had  done,  and  he  resented  the  proposal  that  it  also  should  be  removed. 
Mercury  and  iodide  quickly  cured  him. 

Hodgkin's  Disease  (Lymphadenoma). — A  condition  as  yet  ill- 
understood  ;  sometimes  resembles  tubercle,  sometimes  sarcoma,  in 
its  clinical  course. 

The  enlarged  glands,  which  are  characteristic  of  it,  may  remain 
for  long  unchanged,  then  slowly  soften,  redden  on  the  surface,  break 
down,  discharge  a  curdy  matter,  and  finally  heal.  The  patient  with 
this  form  of  the  disease  may  live  for  several  years.  In  the  second 
type,  the  glands  become  glued  together  and  fixed ;  internal  deposits 
form  quickly,  and  the  patient  dies,  with  dissemination  throughout 
the  viscera. 

Fibrosis. — Natural  cure  occurs  in  all  of  these  diseases.  It  is 
the  rule   in   syphilis  ;  the  exception   in    tubercle  ;   and  very  rare  in 


MALIGNANT     DISEASE  59 

cancer.     In  all  of  them,  the  cure  of  the  local  lesions  is  the  result  of 
fibrosis. 

The  tendency  to  break  down  is  characteristic  of  the  acute  type 
of  tubercle,  syphilis,  and  malignant  disease  ;  and  to  fibrose  is 
characteristic  of  the  chronic  variety. 

The  natural  tendency  of  fibrous  tissue  to  contraction  accounts 
for  the  fact  that  stricture  of  the  tubular  viscera  may  be  the  result  of 
tubercle,  of  syphilis,  or  of  cancer. 

In  all,  the  newly-developed  fibrous  tissue  may  grow  so 
luxuriantly  as  to  form  a  tumour,  chiefly  fibromatous.  Keloid  of 
the  skin,  and  many  internal  growths,  are  of  this  nature ;  and 
in  each  of  them  the  chief  clinical  characteristics  are  slow 
development  and  long  duration,  with  periods  of  quiescence 
(fibrosis  or  sclerosis  in  excess),  and  exacerbation  (infection  in 
excess). 

In  the  prognosis  of  cases  of  cancer  everything  depends  upon 
the  amount  of  existing  fibrosis.  The  ill-defined  diftuse  growths, 
so  active  as  to  simulate  inflammatory  swellings,  offer  the  worst 
prognosis.  The  firmer,  more  defined  growths,  resembling  simple 
tumours  in  their  physical  characteristics,  are  the  most  favourable 
in  prognosis. 

A  growth,  rich  in  cells,  and  without  much  fibrous  tissue,  will 
rapidty  disseminate  and  kill. 

I  have  known  a  patient  die  of  breast  cancer  within  three  months 
of  its  appearance.  On  the  other  hand,  one  patient  under  my  care 
lived  for  twenty-five  years  after  two  operations  for  breast  cancer, 
both  of  which  failed  to  remove  the  growth,  and  were  followed  by  an 
inoperable  recurrence.  Death  resulted  from  extension  of  the  cancer 
to  the  pleura  and  lung.  From  time  to  time  I  had  the  opportunity 
of  watching  the  great  fight  between  cancer  and  fibrosis ;  and  though 
complete  healing  never  occurred,  the  supremacy  of  the  external 
fibrous  tissue  was  maintained  till  the  end.  This  was  at  the 
expense  of  much  discomfort  to  the  patient,  for  the  right  side  of 
her  chest  was  tightly  bound  and  contracted  by  thick  large  patches 
of  scar  tissue. 

Many  cases  of  atrophic  scirrhous  cancer  of  the  breast  have  lived 
for  vears  without  much  discomfort ;  and  have  frequently,  in  the  end, 
died  through  bone  infection.  They  owe  their  benign  course  to  fibrous 
tissue  formation.  Some  of  them  assume  a  more  malignant  course 
after  operation,  and  in  view  of  what  has  been  said,  the  explanation 
is  obvious. 

Cancer  of  the  colon  may  be  one  of  the  most  malignant,  or  one 
of  the  most  benign  of  malignant  growths. 

If  it  takes  the  form  of  a   tumorating    ulcer,    without  stricture, 


60 


SYPHILIS,     TUBERCLE,     AND 


its  course  is  malignant  {Fig.  54)  ;  if,  on  the  other  hand,  stricture 
(i.e.  librosis)  is  the  predominating  feature,  a  better  prognosis  can 
be  offered   {Fig.  55). 

Tuberculous  glandular  tumours  of  long-standing  are  chiefly 
composed  of  fibrous  tissue. 

A  patient  of  mine  carried  about  a  testicle  the  size  of  a  cocoanut 
for  twenty  years,  before  it  troubled  him  sufficiently  to  require 
removal.     It  was  syphilitic,  but  consisted  chiefly  of  fibrous  tissue. 


Fig.  54. — X,ARGE  Ulcerating  Carcinoma  of  I,arge 
Intestine. 

Malignant  varietj-,  with  little  obstruction  and  little 
fibrosis. 


Pig-   55- 


-Constricting  Carcinojia  of 
I,arge  Intestine. 


Chief  signs,  intestinal  obstruction  and  marked 
fibrosis. 


Bones. — For  bone  sarcomata,  the  rule  corresponds  exactly 
with  that  discussed  above.  Their  malignancy  may  be  gauged  by 
the   amount  of  osseous  tissue  in  relation  to  them. 

The  least  malignant  (myelomata)  {Figs.  56  and  57)  have  an 
even,  rounded  shape,  and  may  not  destroy  life  for  many  years. 
They  are  enveloped  in  a  well-defined  bony  capsule,  which  may 
expand  indefinitely  with  their  growth.  If  the  soft  growth  be 
thoroughly  scooped  out  of  its  bony  capsule    a   cure  results,  but   if 


MALIGNANT     DISE  AS  E 


61 


they    burst    through    this    capsule,    they    infiltrate    the    surrounding 
tissues,  grow  rapidly,  and  declare  their  malignancy. 


Fi^s.  56,  57. — Illustrating  the  Growth  of  Bone  TuMotit. 

{C.T)  Cartilage  of  head  of  tibia.     (R.C)  Bony  capsule.     Note  thickness  when  the  tumour  is  small, 
becoming  thinner  as  it  grows.  . 


62 


SYPHILIS,     TUBERCLE,     AND 


The  most  malignant  of  malignant  tumours  are  the  so-called 
periosteal  sarcomata  of  growing  bones.  They  spring  from  the  bone, 
and  their  favourite  site  is  in  the  neighbourhood  of  the  most  active 
epiphyses.  (Upper  end  of  humerus,  lower  end  of  radius,  lower  end 
of  femur,  upper  end  of  tibia.)  Their  growth  is  so  rapid  that  they 
assume  an  irregular  lobulated  form  ;  and  any  resistant  structure  met 
with,  such  as  tendon,  blood-vessel,  or  nerve,  leaves  its  mark  on  their 
surface,  because  in  their  hurry  to  get  big,  they  follow  the  path  of 


Figs.  58,  59. — "  Periosteal  "  Sarcoma. 
Note — {G.G.)  Grooves  for  hamstring. 


least  resistance  {Figs.  58  and  59).  Their  victims  die  within  the 
year,  usually  from  growths  in  the  lung,  and  whether  the  most 
radical  operation  is,  or  is  not,  done. 

In  the  intermediate  group  of  bone  sarcomata — those  of  neither 
very  slow  nor  very  rapid  growth — the  degree  of  malignancy  may  be 
estimated  by  the  amount  and  density  (shown  by  ^r-rays)  of  the  osseous 
tissue  connected  with  them  {Fig.  60).  Some  of  them,  after  years  of 
slow  growth,  suddenly  develop  their  malignant  tendency,  owing  to 
the  fact  that  the  tumour-cells  have  overpowered  their  osseous  inhibitor. 


MALIGNANT     DISEASE 


63 


Like  the  pyogenic  infections,  those  of  tubercle,  cancer,  and 
syphihs,  can  be  imprisoned  by  fibrous  tissue  and  bony  deposits  for 
long  periods  of  time. 

Septic  Infection. — 

The  evil  influence  of 
septic  infection  on 
tubercle,  malignant  dis- 
ease, and  syphilis,  is 
insufficiently  recognized. 
Each  may  have  a  rela- 
tively benign  course  till 
sepsis  is  superadded. 
An  uncomplicated 
tuberculous  abscess 
never  causes  constitu- 
tional disturbance  or 
death,  but  when  septic 
infection  has  gained  an 
entrance  to  it,  both  fre- 
quently follow. 

Most  of  the  pain, 
the  odour,  and  the  dis- 
charge of  cancer,  are 
due  to  superadded  sep- 
sis. One  of  the  con- 
ditions in  which  they 
are  all  pronounced,  is 
cancer  of  the  uterine 
cervix.  I  have  had 
opportunities  for  ob- 
serving elderly  spinsters 
with  this  disease.  In 
all,  the  only  early 
symptom  was  haemor- 
rhage. Before  the 
growth  had  caused 
serious  disturbance,  it 
had,  in  each  instance, 
invaded  the  bladder, 
was  infiltrating  the 
surrounding  structures,  and  had  become  inoperable. 

The  uncomphcated   primary    "  sore  "  of  syphilis  is  not  a    sore 
at  all,  but  a  hard,  dry,  raised,  painless  lump. 


Fig.  60. — "Periosteal"  Sarcoiia. 
Upper  end  of  humerus.       Xote  ossification. 


64 


SYPHILIS 


Chronic  Lymphatic  CEdema. — Amongst  other  causes  of  chronic 
lymphatic  oedema  of  the  extremities,  tubercle,  syphilis,  and  cancer 
have  to  be  remembered. 

Combinations. — That  of  syphilis  and  tubercle  is  a  deadly  com- 
bination. I  have  seen  cases  in  which  tubercle  attacked  the  lungs 
of  a  victim   of  secondary  syphilis.     In   each  instance,  the  tubercle 

rapidly  advanced  to  a 
fatal  issue. 

The  most  disastrous 
form  of  "  scrofula "  is  a 
combination  of  congenital 
syphilis  and  tubercle  {Fig. 
6i). 

Cancer  and  syphilis 
are  very  firm  allies  ;  and 
syphilis  often  provides  a 
suitable  site  for  the  lodg- 
ment of  cancer.* 

Tubercle  and  cancer 
favour  the  same  sort  of 
soil.  Persons  who  have 
recovered  from  tubercle  in 
their  youth  are  exception- 
ally liable  to  cancer  in  their 
later  years.  It  is  more 
than  a  coincidence,  that 
both  occur  in  families  with 
a  history  of  some  members 
having  attained  to  an  ex- 
traordinarily long  life. 


fig.  6i.— Mixed  Syphilitic  and  Tuberculous 
Desiructiox  of  Face. 


Syphilis. 

Syphilis  is  acquired  or  congenital. 

The  cause  is  Spirochcvta  pallida,  a  dehcate  spirillum.  [Plate  II, 
Fig.   C.) 

This  organism  is  readily  destroyed  by  heat,  and  loses  its  infective 
properties  a  few  hours  after  removal  from  the  body. 

Syphilis  is  chiefly  a  venereal  disease  ;  but  may  be  contracted  in 
other  ways  (Syphilis  insontium)  :  pipes,  wind  instruments,  infected 
clothing,  kissing,  vaccination,  etc. 


*  If   a  person  over  sixty  years  of   age   contracts  syphilis,  his  death  from  cancer 
may  be  anticipated. 


SYPHILIS  65 

For  practical  purposes  three  stages  are  recognized — primary, 
secondary,  and  tertiary. 

The  Primary  stage,  absent  for  inherited  syphihs,  occupies  four 
to  eight  weeks,  and  includes  the  period  of  incubation,  the  primary 
sore,  and  the  enlargement  of  the  nearest  glands. 

The  Secondary  stage  occupies  two  years,  and  includes  the  sym- 
metrical and  superficial  lesions  of  skin  and  mucous  membranes,  and 
general  enlargement  of  the  lymphatic  glands. 

The  Tertiary  stage  is  characterized  by  infiltration  of  the  deeper 
tissues  and  internal  organs,  as  well  as  of  the  skin  and  mucous  mem- 
branes, with  fibro-cellular  deposits  ;  the  arteries,  especially,  are  apt 
to  be  diseased.     This  stage  may  be  of  life-long  duration. 

Immunity  is  generally  conferred  by  one  attack. 

The  Primary  Sore  is  a  round,  itching,  painless  elevation,  which 
may  become  an  ulcer  or  an  abrasion  with  a  hard  base  as  its  chief 
characteristic.  It  appears  about  one  month  after  the  infection. 
The  hardness  of  the  base  has  been  emphasized  by  comparing  it  to 
cartilage.  The  inguinal  glands,  throughout  their  whole  chain,  on 
both  sides,  are  of  shotty  hardness,  and  feel  like  almonds.  Any  part 
of  the  penis  may  be  involved  ;  but  a  favoured  site  is  the  angle 
between  "the  base  of  the  glans  and  prepuce.  Sometimes  a  hard 
lymphatic  cord  can  be  felt  on  the  dorsum  of  the  penis  running 
towards  the  glands. 

In  females,  the  primary  sore  may  be  difficult  of  recognition.  It 
is  usually  on  the  labia. 

In  non-venereal  cases,  the  lips  and  nipples  in  women,  and  the 
fingers  in  men,  are  the  most  common  sites. 

Diagnosis  of  Chancre. 

The  hard  chancre  is  nearly  always  solitary  :  hardness  is  the 
striking  feature,  and  when  uncomplicated,  it  seldom  leaves  a  scar. 

It  has  to  be  distinguished  from  the  soft  sore,  or  chancroid.  This 
is  generally  multiple  ;  appears  three  to  six  days  after  infection  ;  shows 
signs  of  active  inflammation  ;  the  ulcers  rapidly  extend ;  the  lymph 
glands  are  more  enlarged,  more  tender,  more  inflamed,  and  suppurate 
often  ;  the  whole  chain  on  both  sides  is  not  infected  as  in  syphilis  ; 
and  the  sore,  on  healing,  leaves  a  scar. 

There  may  be  a  double  infection — syphilis  and  a  soft  sore.  For 
six  weeks  it  will  be  impossible  to  say  there  is  no  syphilis  by  ordinary 
examination.  On  the  other  hand,  examination  of  the  discharge,  or 
of  a  scraping,  may  show  the  spirocheeta,  and  the  diagnosis  is  then 
certain. 

5 


66  SYPHILIS 

Epithelioma  may  be  mistaken  for  the  primary  sore.  It  usually 
occurs  in  patients  over  50  3^ears  of  age,  and  there  is  generally  a  history 
of  chronic  phmiosis. 

Herpes  preputialis  may  also  occasion  doubts.  It  commences  a 
few  days  after  intercourse,  with  red,  itchy  spots  which  develop 
vesicles,  secondarily  small  sores,  and  then  crusts. 

Secondary  Syphilis  appears  from  six  to  twelve  weeks  after  the 
infection,  as  a  measly  rash,  distributed  to  the  skin  symmetrically,  and 
on  the  mucous  membranes. 

Diagnosis  of  Secondary  vSyphilis. 

There  are  fever,  muddy  anaemia,  headache,  pain  in  the  bones, 
general  enlargement  of  the  lymphatic  glands,  and  leucocytosis 
(increase  of  the  leucocytes). 

Six  Qualifications  of  a  Syphilitic  Eruption. — At  a  later  period 
the  skin  shows  : — 

1.  Symmetrical 

2.  Copper-coloured 

3.  Rounded  or  oval 

4.  Polymorphic 

5.  Not   itchy,  spots 

6.  Which  yield  to  treatment. 

When  surrounding  the  forehead  at  the  roots  of  the  hair,  the 
spots  have  been  described  as  the  "  corona  veneris." 

The  Nails  exhibit  syphilitic  cracks  and  onychia. 

The  Hair  is  dry,  and  falls,  or  can  be  readily  pulled  out. 

Mouth. — At  the  angles,  a  patch  with  a  central  crack  is  very 
characteristic. 

Tongue. — "  Snail-track  "  ulcers.  Bald  area?  on  the  dorsum  and 
at  the  sides,  mucous  patches,  and  cracks. 

Throat. — The  tonsils  and  palate  show  grey  snail-track  ulcers. 

Nose. — Crusts  on  the  mucous  membrane  of  the  septum. 

Eyes. — From  fourth  to  seventh  month — iritis,  choroiditis,  and 
neuro-retinitis. 

Ears. — There  may  be  middle-ear  infection  from  the  throat. 

Bones. — Periosteal  nodes  which  have  been  associated  with  head- 
ache, nocturnal  pains  in  the  limbs,  and  tenderness  on  pressure.  These 
are  often  marked  over  the  sternum. 

Anus  and  Genitals. — Condylomata,  or  warts  {Fig.  62). 

Later  Secondary  Period. — There  may  be  synovitis — especially 
of  the  knees  ;  double  epididymitis  ;  evidences  of  diffuse  cerebral 
involvement  ;  and  palmar  and  plantar  psoriasis. 


SYPHILIS 


67 


Tertiary  Syphilis. — The  signs  of  this  may  appear  from  the 
second  year.  The  lymphatic  glands  are  now  not  generally  enlarged  ; 
the  manifestations  are  not  symmetrical ;  they  are  those  of  a  localized 
infection  ;   they  select  the  least  vascular  sites. 


-Venereal  Warts. 


The  lesion  is  a  gmiima  which  consists  of  three  principal  zones  : 
(i)  Central  necrosis  :  (2)  Beyond  this,  round  cells  ;  (3)  Outside  of 
all,  fibrosis  {Fig.  63). 


/•I?.  63. — Diagram  of  Breaking-down  Guiisla  or  Tubercle. 

j  4.     Area  of  small  round  cell  infiltration. 

5.  Area  of  endothelial  infiltration  and  fibrosis. 

6.  Normal  tissue. 


1.  Central  necrotic  area. 

2.  Liquefied  tissue. 

3.  Pyogenic  membrane. 


68 


SYPHILIS 


When  the  necrotic  centre  is  exposed,  its  appearance  is  that  of  a 
wash-leather  slough. 

When  the  slough  separates,  the  typical  syphilitic  ulcer  is  left.* 

When  the  ulcer  heals,  there  is  a  marked  cicatrix,  tending  to  a 
circular  shape,  and  pigmented  round  about  {Fig.  64). 

Giwimata  of  the  Skin  choose  the  mid-line  of  the  body,  and 
neighbourhood  of  the  knees.  Over  the  deltoids,  the  buttocks,  and 
the  back,  are  also  favourite  sites.  The  face  is  especially  liable  to 
obstinate  ulcers,  and  its  middle  line  is  a  favourite  situation. 

The  Bcnes. — Gummata  of  the  periosteum,  or  deep  gummata, 
ma}^  occur.     The  latter  may  allow  of  spontaneous  fracture. 


Fig.  64. — Gummatous  Ulceratiox  of  Buttocks. 

Extensive  caries  and  necrosis  may  follow  septic  infection  of  the 
syphilitic  bone. 

Bones  specially  liable  are  the  nasal,  and  those  of  the  hard  palate, 
cranial  vault,  and  sternum. 

In  the  long  bones  a  chronic  inflammatory  swelling  in  the  diaphysis 
is  likely  to  be  syphilitic  {Figs.  65  and  66.) 

Muscles. — The  majority  of  muscle-tumours  are  gummata. 

Mouth. — Scarring  at  the  angles,  especially  marked  in  congenital 
syphilis,    is    pathognomonic.       Other    evidences     are     leukoplakia, 


*  Always  suspect  syphilis  as  the  cause  of  an}'  ulcer  which  endeavours  to  heal 
for  a  time,  then  suddenly  breaks  down  again,  and  spreads,  as  if  mouse  eaten,  at 
one  part  of  its  edge. 


SYPHILIS 


69 


giimmata  and  depressed  cicatrices  of  them,  of  the  tongue  (dorsum, 
affecting  chiefly  the  midhne),  perforations  of  the  hard  or  soft  palate, 
absence  of  the  uvula,  scars  and  adhesions  of  the  soft  palate,  chronic 
inflammations  and  ulceration  of  the  larynx,  and  necrosis  of  the 
laryngeal  cartilages. 

Nose. — Perforations  of  the  septum,  sunken  bridge,  ozoena. 

Eyes. — Signs  of  old  iritis  or  choroiditis. 

Viscera. — In  the  testes,  liver,  and  spleen,  gummata  may  be 
found  ;   and  these  can  soften  and  break  down,  or  cause  fibrosis. 

Rectum. — This  may  show  ulcers,  fistulce,  and  stricture. 


Fig.  65. --Syphilis  Osteitis. 

Brain  and  Spinal  Cord. — Gummata  may  be  found,  and  these 
produce  the  clinical  signs  of  tumour.  The  cerebral  arteries  may  be 
diseased  or  obliterated,  or  aneurysms  may  be  present.  Paralysis  of 
nerves  is  one  of  the  common  signs  of  intracranial  syphilis.*  Chronic 
meningitis,  causing  headache  and  nerve  involvement ;  myelitis. 
General  paralysis  and  locomotor  ataxia  are  now  well  recognized 
results  of  old  syphilis. 

Blood-vessels. — (Arteries.)  Arteritis,  affecting  chiefly  the  inner 
and  muscular  coats,  and  causing  aneurysm  and  thrombosis. 


*  Headache— prolonged    and    severe - 
suggest  a  syphilitic  lesion. 


-insomnia,    double    vision,    and    strabismus. 


70 


SYPHILIS 


Congenital  Syphilis. — The  family  history  is  one  of  abortion  and 
still-birth,  produced  by  placental  disease,  or  by  disease  of  the 
foetal  viscera. 

Signs. — These  appear  at,  or  soon  after  birth— usually  three  to 
six  weeks  after — but  may  be  as  late  as  thirty  years. 


Fig.  66. — Sclerosis  of  Bone. 
S.vphilitic  osteitis  of  tibia.     Diaphyseal  infection. 


Snuffles ;  sores  round  anus  ;  hoarse  cr\^ ;  are  generally  the 
first  signs. 

Skin. — Diffuse  dermatitis  ;  peeling  ;  copper  spots  ;  or  pemphigus. 

Mouth. — Ulcers  round  orifice  externally  leave  radiating  scars. 
Stomatitis  ;   decayed  teeth  ;  high  palate. 

Amis  and  Genitals. — Condylomata. 

Skull. — Craniotabes.     Parrot's  nodes. 


SYPHILIS 


71 


Bones. — Epiphysitis,  with  pseudo-paralysis.  Arthritis,  which 
often  suppurates. 

General  Appearance. — A  syphihtic  baby  may  look  healthy  when 
born,  and  later  frequently  looks  like  a  shrivelled,  anaemic  old  man. 

With  treatment,  cure  follows,  and  after  one  year  may  remain 
permanent. 

Later   Signs  (during  puberty  and  adolescence)  ; — 

Eyes. — Interstitial  keratitis  ;  choroiditis. 

Month. — Radiating  scars.  Hutchinson's  teeth  {Fig.  67)  (a  notch 
in  the  permanent  set  of  incisor  teeth)  ;  peg-top  teeth ;  palatal 
ulceration. 


Fiq.  67. — Hutchinson's  Teeth. 
From  a  case   of  congenital  syphilis 


Nose. — Sunken  bridge  ;  gummatous  ulcers  on  skin. 

Ears. — Deafness — due  to  disease  of  the  auditory  nerve,  or  of  the 
internal  ear. 

Bones. — Thickening  from  sclerosis,  may  be  symmetrical ;  Parrot's 
nodes  (on  frontal  and  parietal  eminences)  ;  craniotabes. 

Joints. — Symmetrical  synovitis. 

Skin. — Deep,  large,  obstinate  gummata. 

General. — Whole  body  may  be  dwarfed. 

The  spirochaeta  has  been  found  in  all  syphilitic  lesions,  primary, 
secondary,  and  tertiary  ;  the  Wassermann  reaction  is  present  in  the 
great  majority  of  cases. 

It  is  obvious,  therefore,  that  in  every  stage  the  infection  of 
syphilis  may  be  conveyed  to  others.  Experience  has  proved,  how- 
ever, that  the  chancre  and  its  site  are  highly  infective  ;  secondary 
lesions,  except  at  the  chancre  site,  little  infective  ;  and  tertiary  lesions, 
practically  not  so  at  all.  The  shorter  the  period  since  infection 
occurred,  the  more  active  the  organisms  are.     It  seems  as  if,  on  their 


72  SYPHILIS 

first  entrance  to  the  body,  they  swarm  unhindered  everywhere,  causing 
a  general  toxaemia  ;  that  later,  there  is  an  increasing  tendency  to 
localization  ;  and  that,  finally  (tertiary  stage),  the  lesions  are  entirely 
local,  depending  on  spirochaetae  imprisoned  in  cells  of  fibrous  tissue. 
Whether  these  confined  organisms  are,  or  are  not,  to  work  mischief 
in  the  future,  depends  more  upon  the  tissue  resistance  than  upon  any 
other  factor. 

Treatment. 

There  is  nothing  so  remarkable  in  medicine  as  the  effect  of 
treatment  upon  syphilis. 

The  Primary  Sore. — If  the  prepuce  is  long,  and  its  orifice 
narrow,  it  is  essential  as  a  first  step  to  enlarge  the  opening  by  knife 
or  scissors,  sufficiently  to  allow  of  quite  easy  retraction.  Neglect  of 
this  precaution  ma}^  result  in  balanitis,  gangrene  of  the  prepuce,  and 
possibly  phagedaena.  For  the  treatment  of  this  last  very  serious 
complication,  continuous  immersion  in  a  hot  bath  is  the  most  suit- 
able remedy.  Black  wash,  applied  on  lint  and  frequently  renewed, 
is  an  excellent  dressing  for  the  chancre. 

So  soon  as  diagnosis  is  assured  by  the  discovery  in  a  scraping 
of  the  spirochaeta,  by  the  typical  induration  of  the  chancre  and 
enlargement  of  the  whole  chain  of  inguinal  glands,  by  the  appearance 
of  a  polymorphous  eruption,  or  by  a  positive  Wassermann  reaction, 
the  administration  of  mercury  should  be  commenced. 

My  preference  is  strongly  in  favour  of  the  inunction  method, 
but  social  and  other  considerations  are  usually  against  this,  and  a 
substitute  has  to  be  found. 

This  is  my  usual  prescription  : — 

B     Hydrarg.  Perchlor.      -     -     -     -  gr.  j 

Potass.  lodid.     ------  jiss 

Aq.  ----------ad  5viij 

A  table.spoonful  to  be  taken  three  times  a  day  in  a  wineglassful  of  water. 

The  medicine  is  to  be  continued  for  three  months,  or  until  all 
the  ordinary  signs  of  disease  have  disappeared  ;  then  left  off  for  a 
fortnight ;  and  at  the  end  of  this  "  holiday,"  resumed.  On  these 
Mnes  the  course  is  continued  during  the  first  year. 

During  the  second  year,  if  there  have  been  no  recent  outbreaks, 
the  medicine  is  taken  for  two  months  out  of  three,  and  must  be 
continued  at  the  same  rate  till  one  year  has  passed  without  any  signs 
of  disease.  All  my  patients  are  recommended  to  take  a  similar 
course  during  the  whole  of  the  months  of  April  and  October,  for  the 
next  seven  years. 


SYPHILIS  13 

It  is.  however,  probable,  that  scientirie  tests  will  soon  take  the 
place  of  these  empirical  rules,  and  that  the  progress  of  the  patient 
will  be  guided  by  accurate  laborator}^  records. 

During  the  mercurial  course,  it  is  essential  that  regular  attention 
should  be  given  to  the  teeth  and  mouth,  as  any  neglect  of  these  may 
result  in  so-called  mercurial  stomatitis. 

There  are  some  conditions  which  can  be  much  relieved  by  local 
treatment. 

Mucous  patches  in  the  mouth  and  on  the  tonsils  may  be  painful 
and  depressing  from  interference  with  the  functions  of  mastication  and 
deglutition.  Thev  only  become  serious  in  the  mouths  and  throats  of 
persistent  smokers  ;  and  the  chief  indication  is  to  use  tobacco,  if  at  all, 
in  very  moderate  quantity,  and  in  the  least  irritating  form — through 
a  long  pipe.  Each  spot  may  also  be  painted  daily  with  a  camel-hair 
brush  dipped  in  a  solution  of  chromic  acid,  ten  grains  to  the 
ounce.  The  patient  may  at  the  same  time  gargle  the  mouth  and 
throat  after  every  meal  with  a  solution  of  chromic  acid,  one  graui  to 
the  ounce. 

Skin  eruptions,  especially  on  visible  surfaces,  always  cause 
annoyance.  Their  disappearance  may  be  hurried  by  rubbing  on  to 
the  spots  each  night  an  ointment  of  hydrarg.  ammoniata  gr.  xx, 
vaseline    3]- 

Condylomata  in  connection  with  the  anus  and  genital  organs 
get  well  quickl}-  if.  after  careful  washing  and  drying  two  or  three 
times  a  day,  they  are  dusted  with  equal  parts  of  calomel  and  kaolin, 
the  moist  surfaces  being  kept  apart  with  absorbent  cotton-wool. 

Iritis  should  be  anticipated,  and  the  patient  told  of  its  possible 
commencement  as  a  redness  of  the  eye,  which  demands  attention.  It 
occurs  chiefly  in  those  affected  by  a  papular  eruption  of  the  skin,  and 
the  pupil  should  be  at  once  dilated  with  atropine  in  a  4  grs.  to  the  oz. 
solution. 

Xervous  Svniptouis. — The  appearance  of  nervous  symptoms, 
cerebral  or  spinal — and  these  may  occur  during  the  secondary  period 
— demand  energetic  treatment  by  inunction. 

Infants. — For  the  treatment  of  infants,  the  old-fashioned  method 
of  spreading  half  a  drachm  of  unguent,  hydrarg.  three  times  a  week 
on  the  abdominal  binder  is  hard  to  beat. 

Children. — For  older  children,  one  grain  of  hydrarg.  c.  cret.  may 
be  given  twice  a  day. 

The  manifestations  of  tertiary  syphilis — gummata,  ulcers,  etc. — 
are  influenced  for  good  by  increasing  the  amount  of  iodide  of  potash. 
In  cases  of  cerebral  syphilis,  for  example,  30  grs.  of  iodide  and  yV  gr. 
of  hydrarg.  perchlor..  taken  in  half  a  tumblerful  of  water  three  times 


74  SYPHILIS 

a  day,  may  be  continued  until  all  active  symptoms  have  disappeared. 
Man}'  of  the  chronic  external  gummata  can  be  hurried  away  by  the 
application  of  a  blister,  or  a  series  of  blisters,  and  for  the  more 
chronic — for  example,  those  affecting  adolescents,  or  adults  who  are 
the  victims  of  congenital  syphilis — the  most  satisfactory  method  is 
to  dissect  them  out  if  they  are  in  accessible  situations. 

A  healthy,  simple  life,  abundant  fresh  air,  frequent  hot  baths, 
milk,  eggs  and  cream,  and  freedom  from  excessive  alcohol  and 
tobacco,  are  also  essential  to  the  best  results. 

So  much  emphasis  has  of  late  years  been  attached  to  the  serious 
aspect  of  syphilis,  and  its  possibilities  of  far-reaching  mischief,  that 
there  seems  little  danger  of  these  being  overlooked.  There  is,  indeed, 
some  chance  that  too  unfavourable  a  prognosis  may  be  formed,  and 
I  would  like  to  dispel  some  of  the  gloom.  Before  coming  to  Newcastle, 
I  was  in  practice  in  a  seaport  town  (population  70,000)  for  thirteen 
years,  and  had  large  opportunities  of  watching  the  effects  of  syphilis, 
extending  now  over  several  years.  Many  of  the  patients  I  have 
known  for  as  long  as  twenty  years,  so  that  it  is  possible  to  form 
some  conclusions. 

The  first  is,  that  intemperance  in  alcohol  and  tobacco  are  the 
greatest  dangers  to  syphilitics. 

Next,  that  syphilis  has  such  a  strong  tendency  to  spontaneous 
recovery  in  healthy  young  adults,  that  the  majority  recover  from  its 
effects,  and  suffer  from  no  serious  sequelae  if  entirely  untreated. 

That,  with  careful  treatment  on  the  lines  indicated,  perfect 
recovery  may  be  expected  ;  and  that  after  three  years,  if  an  interval 
of  one  year  entirely  free  from  symptoms  has  elapsed,  it  is  safe  to 
marry. 

That,  in  at  least  90  per  cent  of  cases,  no  serious  after-effects 
occur. 

Tuberculosis. 

Cause. — The  most  common  cause  of  chronic  inflammation  is  the 
tubercle  bacillus.  It  gains  an  entrance  to  the  body,  in  surgical  tuber- 
culosis at  least,  chiefly  by  the  mouth  and  alimentary  canal  ;  effects 
an  entrance  to,  and  acquires  a  lodgment  in,  lymphatic  glands  ;  and 
is  distributed  by  the  lymphatic  vessels. 

Abdominal  surgery  shows  that  a  large  percentage  of  the  popula- 
tion carry  mesenteric  glands  infected  by  tubercle  from  childhood 
throughout  hfe. 

The  chief  predisposing  conditions  for  its  successful  attack  are 
those  diminishing  the  vital  resistance  of  the  body. 


TUBERCULOSIS  75 

Two  types  of  person  arc  universally  recognized  as  being  more 
than  usually  susceptible  to  this  disease. 

1.  The  pretty,  soft-skinned,  vivacious,  blue-eyed,  fair,  soft- 
haired,  lymphatic  type. 

2.  The  ugly,  coarse-skinned,  sluggish,  brown-eyed,  dark,  rough- 
haired,  phlegmatic  type. 

A  considerable  growth  of  downy  hair  on  the  body  is  perhaps 
the  most  suggestive  sign  of  the  tendency  to  tubercle.  The  pale- 
complexioned,  red-haired,  freckled,  hairy-skinned  Celt  is  specially 
disposed  to  tubercle  (and  sarcoma).  Childhood  and  early  3'outh  are 
the  favourite  ages  for  its  occurrence. 

Pathology. — A  typical  microscopical  tubercle  consists  of  a  centre 
(giant  cell) ;  beyond  this,  a  circle  of  endothehal  cells  ;  and  outside,  a 
layer  of  round  cells  ;  with  other  manifestations  of  inflammatory 
reaction.  A  number  of  these  join  to  form  a  miliar}^  tubercle  (the 
smallest  to  be  seen  with  the  naked  eye). 

Tubercle  bacilli  may  be  demonstrated  in  the  nodules  by  micro- 
scopic examination ;  or  failing  this,  their  presence  may  be  proved  by 
animal  inoculation. 

The  centre  of  the  tuberculous  mass  tends  to  break  down  from 
defective  blood  supply,  and  to  soften  (caseate),  or  liquefy  and  point 
(cold  abscess).  A  natural  cure  may  follow  its  spontaneous  discharge. 
More  commonly,  septic  infection  of  the  tuberculous  focus  follows, 
and  the  serious  results  of  a  mixed  infection  declare  themselves. 
Natural  cure  may  also  follow  calcification  of  the  tuberculous  area,  or 
its  imprisonment  by  fibrous  tissue  ;  but  the  tubercle  bacilli,  under 
these  conditions,  may  still  live  and  reassert  themselves  later. 

Cold  Abscess. — Tuberculous  (cold)  abscess  is  one  of  the  most  im- 
portant and  frequent  surgical  manifestations  of  tubercle.  Important, 
because  the  failure  to  treat  it  properly  is  so  often  the  cause  of  pro- 
longed invalidism  and  a  painful  death  ;  and  frequent,  because  chronic 
abscess  occurs  in  a  large  percentage  of  tuberculous  bone  infections.* 

The  w'all  of  these  abscesses  consists  of  tuberculous  granulations, 
the  inner  layers  of  which  are  undergoing  caseation,  liquefaction,  and 
disintegration.  The  contents  are  the  debris,  mixed  with  exudate  from 
the  blood-vessels.  A  more  or  less  curdy  fluid  is  the  result,  watery 
fluid  contents  predominating  in  one  case,  masses  of  curdled  lumps 
in  another. 

The  diagnosis  of  such  an  abscess  may  present  difficulties,  as  its 
progress  is  so  painless  and  so  slow  that  it  can  be  mistaken  for  other 
soft  swellings  ;  thus,  a  patient  with  psoas  abscess  not  infrequently 
comes  because  trusses  which  he  has  tried  "  will  not  keep  his  hernia 

*  Where  a  chronic  abscess  is,  look  for  the  focus  in  some  bone. 


76 


TUBERCULOSIS 


up ;  "  and  many  operations  for  the  "  removal  of  fatty  tumours  "  have 
terminated  in  the  discovery  of  a  chronic  abscess. 

For  the   diagnosis   of  the   size,   shape,    and   source   of  the   sinus 
resulting  from  chronic  abscess,  a  useful  method  has  been  added  to  the 


rig.    68. — SlNX'S    FOLLOWING    TUBERCULOUS    DISEASE    OF    HiP    JOINT. 

Injected  with  bismuth  paste. 


resources  of  surgery.  By  the  injection  of  the  sinus  with  a  bismuth 
vaseline  paste,  and  the  use  of  the  Roentgen  rays,  all  of  these  may  be 
accurately  determined  {Figs.   68  and  69). 


TUBERCULOSIS 


77 


Aids  in  the  diagncjsis  of  obscure  cases  of  tuberculosis  are  : — 

1.  The  Injection  of  Koch's  Old  Tuberculin  (a  concentrated  extract 
of  dead  tubercle  bacilli). — After  a  few  hours,  the  diseased  focus 
swells  and  becomes  painful,  the  patient  feels  ill,  and  has  a  rise  of 
temperature  (ioi°-i04°  F.) 

2.  The  Injection  of  New  Tuberculi)i  (T.  R.),  and  observation  of 
its  effects  on  the  opsonic  index. 


^/^//rA 


'i/m. 


Fig.  69. — Explanatory  Diagram  of  Hip  Disease  Sixus. 
Injected  with  bismuth  paste. 


3.  The  Conjunctival  Reaction  (Calmctte). — A  single  drop  of  a 
one  per  cent  solution  of  specially  purified  tuberculin  is  dropped  into 
the  inner  angle  of  the  eye.  If  a  reaction  (redness,  smarting,  and 
lachrymation)  follows  in  a  few  hours,  and  persists  for  at  least  twenty- 
four,  the  result  is  positive  ;  there  is  tubercle  somewhere  in  the  patient. 
There  is,  however,  more  danger  in  using  this  test  than  others,  for 
destructive  inflammation  of  the  eye  has  followed. 

4.  The  Cutaneous  Reaction   (von  Pirquet). — This  test  is  applied 


78  TUBERCULOSIS 

by  rubbing  Koch's  original  tuberculin  (25  per  cent  dilution),  into  a 
small  area  of  skin,  scratched  as  for  vaccination.  A  second  similar 
spot  should  be  made,  and  rubbed  with  glycerin  as  a  contrast.  If  the 
patient  has  tubercle  there  is,  at  the  end  of  forty-eight  hours,  a  rounded 
red  papule  surrounded  by  a  circle  of  inflammatory  blush  and 
perhaps  small  serous  vesicles,  on  the  spot  rubbed  with  tuberculin. 
This  begins  to  disappear  about  the  fifth  day,  and  in  ten  days  is 
gone,  leaving  a  pigmented  area  for  months. 

Treatment. 

The  treatment  of  tubercle  is  (i)  General,  and  (2)  Local. 

The  natural  tendency  to  cure  is  now  receiving,  as  it  deserves, 
fuller  recognition.  The  bad  character  tubercle  has  received  is  due 
chiefly  to  its  septic  complications.  So  soon  as  these  can  be  prevented, 
or  satisfactorily  dealt  with,  the  prognosis  is  materially  improved. 

Before  the  age  of  ten  years,  surgical  tuberculosis  may,  with  a 
moderate  amount  of  patience  and  care,  be  expected  to  recover. 
As  life  advances,  the  prognosis  becomes  increasingly  serious  ;  and 
after  fifty  years  of  age,  recovery  without  a  radical  operation  is 
very  rare. 

I.  General  Treatment  aims  at  improving  the  resisting  power 
of  the  patient. 

The  most  important  aids  are  :  Fresh  air,  night  and  day ;  two 
pints  of  new  milk  and  two  eggs  daily,  in  addition  to  ordinary  food ; 
and  a  general  soft  soap  inunction  every  night,  lathered  off  in  a  hot 
bath,  the  drying  to  be  done  with  a  rough  towel. 

In  certain  instances — and  my  own  experience  points  most 
strongly  to  genito-urinary  tuberculosis — considerable  benefit  is  derived 
from  the  use  of  tuberculin  injections.  The  administration  of  these 
may  be  guided  by  an  estimation  of  the  opsonic  index,  or  by  ordinary 
clinical  signs.  If  the  latter  are  depended  on,  a  minimum  dose  of 
Koch's  new  tuberculin  should  be  injected  tentatively.  If  no  effect 
is  felt,  or  observed,  a  larger  dose  can  be  used  in  a  week's  time.  Too 
large  a  dose  is  likely  to  occasion  headache,  fever,  and  a  feeling  of 
malaise.  A  suitable  dose  is  followed  by  increased  vigour  and  appetite, 
a  general  sense  of  well-being,  and  improvement  in  the  clinical  signs. 
When  the  suitable  dose  has  been  found,  it  should  be  repeated  every 
two  weeks. 

The  opsonic  index  lias  also  been  used  as  an  indication  against 
operation.  It  is  said  that  no  operation  should  be  done  when  the 
opsonic  index  is  low  ;  for  then  general  tuberculosis  will  probably 
result,  through  dissemination  of  the  tubercle  bacilli  as  a  consequence 
of  the  operation. 


TUBERCULOSIS  79 

2.  Local  Treatment. — The  ideal  treatment  for  a  loealized  tuber- 
culous lesion  is,  and  always  will  be,  its  complete  excision. 

This  should,  consequently,  be  the  method  adopted  whenever  the 
operation  can  be  accomplished  without  inflicting  serious  damage. 

Joints. — When  excision  would  entail  serious  damage,  as  in  the 
case  of  joints,  rest  is  the  greatest  curative  agent. 

The  entire  recovery  of  diseased  joints  in  children  may  be  antici- 
pated with  confidence  if  they  are  kept  at  rest  from  one  to  two  years. 

Up  to  thirty  years  of  age  recovery,  with  some  limitation  of 
movement,  is  likely  to  follow  prolonged  rest. 

After  fifty,  cure  does  not  occur  ;  and  amputation  is  usually  the 
best  treatment. 

Next  to  rest,  the  application  of  Bier's  hypercrmia  treatment  is  the 
greatest  ordinary  aid  to  recovery.  Some  surgeons  are  so  enthusiastic 
in  its  favour  as  to  believe  that  this  is  the  most  important  aid,  and  that 
rest  is    no  longer  necessary. 

For  tuberculous  abscesses,  a  small  incision  is  made,  and  Klapp's 
suction-ball  is  applied  for  live  minutes  at  a  time  over  the  opening, 
then  the  ball  is  removed  for  three  minutes,  and  the  process  is 
repeated  time  after  time  for  about  three-quarters  of  an  hour.  The 
small  wound  should  be  dressed,  and  no  drainage  must  be  permitted. 
The  operation  is  to  be  repeated  daily  till  healing  follows. 

For  tuberculous  joints  and  tendon  sheaths,  a  Martin  india-rubber 
bandage  is  applied,  some  considerable  distance  above  the  infected  part, 
for  one  hour  night  and  morning,  and  repeated  daily.  The  bandage 
should  be  tight  enough  to  impede  the  venous  circulation  sufficiently  to 
cause  the  limb  below  it  to  assume  a  reddish-blue  colour,  and  to  swell ; 
but  not  tight  enough  to  cause  any  pain,  still  less  to  arrest  the  arterial 
pulse.    The  occurrence  of  pain  demands  instant  removal  of  the  bandage. 

The  most  brilliant  results  we  have  observed  have  been  in  cases 
where  septic  sinuses  were  serious  complications. 

A  variety  of  injections  have  been  used,  all  with  some  success. 
Iodoform  is  the  chief  constituent  of  most  of  them,  and  probably  they 
all  act  by  stimulating  fibrosis. 

Special  mention  must  be  made  of  the  method  of  injecting  abscesses 
and  sinuses  with  an  ointment  of  arsenic-free  bismuth.  This  is  com- 
posed of  subnitrate  of  bismuth  one  part,  and  white  vaseline  two  parts, 
carefully  sterilized  ;  and  the  cavity  or  sinus  to  be  treated  is  gently 
filled  with  it  by  means  of  a  large  syringe.  Many  obstinate  sinuses 
have  healed  after  a  few  applications  ;  and  good  reports  of  large 
abscesses  healed  by  the  same  means  are  recorded.  At  the  same  time, 
it  is  necessary  to  mention  that  serious  poisoning,  and  occasionally 
active  sepsis,  have  resulted  from  the  use  of  this  method.  If  symptoms 
of  poisoning  occur,  the  sinus  must  be  thoroughly  washed  out  with 


80 


TUBERCULOSIS 


warm  sterilized  olive  oil.  The  chances  of  sepsis  may  be  minimized 
by  careful  use  of  antiseptics  in  the  preparation  of  the  skin  and  the 
mouth  of  the  sinus. 

Psoas  Abscess. — My  own  belief  is,  that  treatment  by  operation 
is  most  satisfactory  in  immediate  and  remote  results.  When  the 
abscess  cannot  be  excised,  as  is  the  case  with  psoas  collections,  my 
method  of  operation  is  offered  as  an  example  of  the  most  serious 
of  these  undertakings. 


Fig.  70. — Caries  of  Spixe. 

Showing  posterior  end  of  incision  for 
psoas  abscess. 


Fig.  71. — iNcisiox  FOR  Cure  of 
Psoas  Abscess. 


The  abscess  is  fully  exposed  by  an  incision  starting  at  the  costal 
margin  above  ;  and  behind,  opposite  the  outer  edge  of  the  quadratus 
lumborum  muscle,  and  continued  obliquely,  parallel  with  the  inter- 
costal nerves,  forward  on  to  the  abdomen  to  the  outer  edge  of  the 
rectus  abdominis  {Figs.  70  and  71).  After  division  of  the  abdom- 
inal muscles  in  this  line,  the  transversalis  fascia  and  peritoneum 
covering  the  abdominal  contents  are  separated  inwards,  till  the  psoas 
abscess  is  fully  exposed.  This  is  then  opened,  and  its  contents 
evacuated.     With   retractors   and   a   search-light,    it  is  now  possible 


TUBERCULOSIS 


81 


to  see  and  deal  with  diseased  areas  on  the  bodies  of  either  the 
lowest  dorsal  or  lumbar  vertebrae.  A  second  incision  is  made  over 
the  femoral  prolongation  of  the  abscess  below  Poupart's  ligament, 
and  with  sharp  spoons,  sluicing,  and  gauze  mopping,  followed  up  by 
the  search-light,  every  part  of  the  abscess  cavity  is  gently  cleansed 
of  any  gross  debris,  and  all  bleeding  is  arrested.  The  entire 
wound  is  closed  without  drainage,  and  the  results  are  surprisingly 
good  *  {Fig.  72). 


Fig.  72. — Psoas  Abscess  Scar  left  after  Operation. 
The  operation  was  done  14  j-ears  ago.     The  patient  is  quite  well  and  strong. 

Case  3. — {Figs.  70  and  71.)  — C.  T.,  aet.  29,  labourer,  admitted 
May  2 1  St,   1900. 

History. — For  the  last  three  years  he  had  suffered  in  the  dorsal  region 
of  back,  and  was  unable  to  work.  Pain  was  worst  on  movement.  The 
affected  region  was  tender  to  the  touch.  When  he  stooped,  the  back 
seemed  to  lock.  Two  months  ago  he  noticed  a  swelHng  in  the  right  groin 
which  caused  him  some  difficult^'  in  flexing  his  thigh. 

Past  History. — Had  pleurisy  four  years  ago,  and  was  off  work  six 
months. 

Family  History. — Sister  died  of  phthisis. 


*  By  passing  a  long,  sharp  spoon  under  the  ligamentum  arcuatum  internum  I 
have  reached,  scraped,  and  appHed  iodoform  paste  to  a  mid-dorsal  vertebra.  Tliis. 
however,  is  not  essential,  for  the  bone  will  heal  with  rest  and  suitable  treatment,  and 
the  complicating  abscess  can  be  successfully  dealt  with  independentlv. 

6 


82  TUBERCULOSIS 

Physical  Signs. — (i)  Swelling  and  deformity  in  mid-dorsal  region  ; 
(2)  Rigidity  ;  (3)  No  pain  on  movement  or  percussion.  Right  groin,  a 
swelling,  with  impulse  on  coughing,  fluctuating,  dull  on  percussion.  Similar 
swelling  above  Poupart's  ligament  ;  fluctuation  from  above  to  below 
Poupart's  ligament. 

Diagnosis. — Spinal  caries  with  large  psoas  abscess. 

Operation. — May  29,  1900.  Pus  evacuated,  and  small  spicules  of  bone. 
Cavity  washed  out,  scraped,  and  iodoform  paste  rubbed  into  cavity  found 
in  vertebrse.  Whole  wound  closed  in  layers ;  no  drainage.  Wound 
examined  after  ten  days — healed.  Cavity  appeared  filled  with  exudate. 
Patient  left  hospital  on  June  29th,  with  poroplastic  jacket. 

December,  1900. — Re-admitted.  Portion  of  external  scar  broken  down. 
Tuberculous  infection. 

1903. — Scar  soundly  healed  ;    no  hernia.     Has  discarded  the  jacket. 

1904. — Gained  three  stones  in  weight.     Working  as  a  miner. 

1909. — Well  and  strong  ;   wound  sound  ;   no  hernia. 

The  danger  in  these  cases  lies  in  the  opportunity  afforded  for 
septic  infection  of  the  tuberculous  contents  of  the  abscess,  and  this 
danger  is  so  serious  as  to  have  induced  some  surgeons  to  advise 
leaving  them  alone  until  the  abscess  dries  up,  or  points  externally. 

If  the  whole  of  the  diseased  tissue  cannot  be  excised,  the  wound 
should — with  few  exceptions — be  left  wholly  open,  and  packed  from 
the  bottom  with  sterile  iodoform-glycerin-formalin  gauze.  This 
allows  of  repeated  applications  to  visible  tuberculous  surfaces  (pure 
carbolic  acid  is  the  best)  ;  it  insures  free  drainage  ;  and  the  local 
defensive  forces  are  stimulated  by  it.  This  method  is  specially  useful 
when  sepsis  is  already  present.  Large  operations  on  these  cases  are 
very  fatal.  When  sepsis  is  present,  an  extensive  operation  should 
only  be  done  in  several  stages.  When  healthy  granulations  cover 
the  whole  w'ound,  it  may  be  closed  by  secondary  sutures. 

Value  of  operation. — The  best  application  of  operation  to  tuber- 
culous disease  is  as  a  probable  preventive  of  extending  mischief  ; 
thus,  operations,  and  even  death  from  generalized  tuberculosis,  may 
be  avoided  by  excision  of  the  first  infected  neck-gland  or  glands  ;  a 
joint  may  be  saved  by  excision  of  a  tuberculous  focus  in  an  epiphysis  ; 
the  whole  remaining  genito-urinary  apparatus  may  be  preserved  by 
the  sacrifice  of  one  kidney,  etc. 


MALIGNANT    DISEASE. 

Tumours  arc  malignant  when  they  arc  heterologous  in  structure 
(have  a  structure  different  to  that  of  the  tissue  in  which  they  are 
formed) ;  when  they  infiltrate  surrounding  tissues  ;  infect  lymphatic 
glands  ;  disseminate  themselves  through  the  body  ;  grow  contin- 
uously and  rapidly  ;    tend  to  recur  after  excision  ;  and  destroy  life. 


MALIGNANT     DISEASE 


83 


Cancer. 

Histologically,  cancer  consists  of  a  riotous  growth  of  epithelium 
which  invades  and  destroys  the  tissues  maintaining  it,  and  which 
extends  through  the  lymphatics. 

The  causes  are  (i)  Predisposing,  and  (2)  Exciting. 

I.  Predisposing  Causes. — 

a.  Chronic  Irritation  is 
one  of  the  chief  of  these. 
The  smoker's  lip  {Fig.  74), 
the  chimney-sweep's  cancer, 
the  paraffin  worker's  ulcer 
{Fig.  73),  the  A'-ray  cancer,  are 
popular  knowledge.  Chronic 
superficial  inflammation  (leu- 
koplakia) of  the  tongue ' and 
cheeks,  the  vulva  and  penis, 
so  often  end  in  cancer  that 
they  are  frequently  and  well 
described  as  pre  -  cancerous 
conditions.  The  irritated  scar  . 
of  a  burn,  sustained  in  3'outh, 
is  certain  to  develop  an  epi- 
thelioma before  the  patient 
arrives  at  the  age  of  fifty 
{Figs.  75,  76,  and  77).  The 
skin  of  a  face  frequently  ex- 
posed to  every  variety  of 
weather  is  likely  to  develop 
skin  cancer  {Fig.  78).  The 
breast  change  described  as 
chronic  interstitial  mastitis  is 
frequently  followed  by  cancer. 

b.  Senility  comes  next  in 
importance  to  chronic  irrita- 
tion as  a  predisposing  cause 
of  cancer.  Two  of  the  most 
common  —  skin  and  breast 
cancers — seldom    occur   before 

forty  years  of  age.  It  is  to  be  remembered,  however,  that  the  term 
"  senility  "  should  refer,  not  so  much  to  the  number  of  years,  as  to 
the  condition  of  the  tissues. 


Fig.  73. — Epitheliojl\  of  Forearm. 
Paraffin  Worker. 


84 


CANCER 


Fig.  74. — Epithelioma  of  I^ip. 
Clay-pipe  smoker. 


Fii;.  75. — HriTHEi.ioMA  following  Unhealed  Burn. 
is-otc— (I)  Pigmentation;   (2)  Scarring;    (3)  Contraction  (permanent  flexion)  and  growth. 


CANCER 


85 


86 


CANCER 


c.  Simple  Tumours. — Certain  simple  tumours,  or  at  least  those 
regarded  as  such  for  years,  predispose  to  cancer.  Warts  (papillo- 
mata  and  polypi)  on  the  skin,  or  in  the  bladder,  the  larynx,  the 
colon,  or  the  rectum,  are  so  likely  to  be  the  precursors  of  cancer, 
that  it  should  be  a  surgical  rule  to  excise  all  of  them,  at  any  rate 
for  patients  older  than  thirty-five  years.  Parotid  tumours,  if  the 
patient  lives  to  old  age,  seldom  fail  to  develop  the  signs  of  malig- 
nancy.    Probably,  all  of  the  tumours  regarded  as  benign  predispose 


Fzg.  78. — Skin  Cancer. 
An  old  field  worker. 


in    less    or    greater   measure    to    cancer.     (See   Cathcart,    on  "  The 
Essential  Similarit}^  of  Innocent  and  Malignant  Tumours.") 
d.  Syphilis  and  Tubercle  prepare  the  ground  for  cancer. 

c.  Worry  is  the  last  of  the  predisposing  causes  worthy  of 
mention.  It  is  impossible,  in  making  a  careful  enquiry  into 
the  history  of  a  number  of  patients,  to  avoid  the  conclusion 
that,  somehow  or  other,  worry  has  materially  helped  them  to 
develop  cancer. 


CANCER 


87 


2.  Exciting  Cause. — The  exciting  cause  still  defies  the  efforts  of 
numberless  investigators  engaged  in  the  search  for  it ;  and  is  unknown. 
Whatever  it  may  be,  cancer  is  spread  over  the  whole  world ;  attacks 
animals  of  all  sorts  as  well  as  man ;  and  is  increasing  in  quantity  as 
well  as  in  malignity. 

There  is  considerable  evidence  in  favour  of  the  view  that  cancer 
is  infectious.  That  it  is  infectious  to  the  person  already  attacked  is 
certain,  for  there  are  too  many  recorded  cases  of  cancerous  sores 
forming  on  points  opposed  to  other  similar  ulcers,  to  be  explained 
away  as  coincidences,  and  the  infection  of  an  operation-wound  by  a 
cancer  cut  into  during  its  removal,  is  universally  recognized  as  a 
danger  to  be  avoided.     That  it  is  infectious  to  others  seems  probable 


Fig.  79. — Epithelioma  of  Side  of  Head. 
Cock's  tr.mour. 


from  evidence  which  has  been  collected  with  regard  to  epidemics  and 
"cancer  houses."  That  it  can  be  transplanted  from  one  animal  to 
another  of  the  same  species,  and  cause  cancer  in  the  animal  so  treated, 
has  been  proved  by  innumerable  experiments. 

Commencement. — It  commences  as  a  single  local  lesion  which, 
with  few  exceptions,  disseminates  more  or  less  rapidly  through  the 
lymphatics,  any  cells  escaping  into  the  blood  being  destroyed.  The 
local  lesion  may  be  a  crack;  an  ulcer;  a  warty  tumour  {Fig.  79)  ; 
or  a  nodule  in  the  substance  of  the  infected  tissue. 

Method  of  Spread. — The  infected  glands  are  those  into  which 
the  lymphatic  vessels  of  the  infected  region  immediately  empty 
themselves ;  and  as  the  lymphatic  vessels  and  glands  offer  consider- 


88  CANCER 

able  resistance  to  the  progress  of  cancer  in  all  cases,  it  remains  for 
some  time  localized. 

When  the  resistance  of  the  lymphatics  has  been  broken  down, 
the  cancer  may  find  an  entrance  to  the  blood-stream  and  become 
disseminated  by  it. 

The  secondary  lesions  always  possess  the  same  character  of  cells 
as  the  primary  growth  ;  that  is,  a  cancer  of  the  rectum  produces  a 
columnar-celled  (rectal-mucous-membrane-cell)  cancer  in  the  liver ; 
the  bone  growths  secondary  to  cancer  of  the  breast,  possess  the 
appearances  characteristic  of  breast  cancer ;  secondary  thyroid, 
and  prostatic  and  kidney  growths  may  be  found  anywhere.  The 
chief  seats  of  secondary  growths  are  serous  membranes,  lungs,  liver, 
kidneys,  and  bones.* 

Classification. 

Cancers  are  classified  according  to  the  variety  of  the  cells  in  the 
tumour. 

Epithelioma  may  occur  in  any  site  covered  by  stratified 
epithelium  :  skin,  mouth,  larynx,  etc.  It  is  chiefly  distinguished  by 
its  local  malignancy,  for  it  rarely  extends  beyond  the  local  lymphatic 
area,  and  kills  by  local  invasion. 


Fis..  80. — Diagram  of  Rodent  TJlcer. 
(C)  Shallow  cavity.     (B)  Smooth,  wire-like  edges.     {A)  Normal  skin. 

One  variety  of  epithelioma,  rodent  ulcer  {Fig.  80),  whose 
favourite  site  is  the  face  in  the  neighbourhood  of  the  lower  eyelid, 
is  only  locally  malignant.  It  springs  from  the  epithelium  of  the 
sweat  or  of  the  sebaceous  glands,  and  never  infects  the  lymphatic 
glands  ;  but  slowly  spreads,  destroying  everything  it  attacks — skin, 
muscles,  bone,  eye,  etc.  In  some  skin  epitheliomata  which  attack 
the  face,  I  have  several  times  seen  spontaneous  healing  occur  ;  but 
in  those  cases  I  have  been  able  to  watch  an  outbreak  at  the  same 
spot  has  sooner  or  later  followed  the  apparent  cure.  In  some  epithe- 
liomata, the  secondary  glandular  infection  assumes  an  appearance 
of  so  much  importance  that  the  primary  lesion  may  escape  all  but 
the  most   careful  observation.     This  is  specially  apt   to  occur  when 


*  When  a  spontaneous  fracture  or  a  bone  tumour  occurs  in  an  elderly  patient, 
examine  the  breast,  the  prostate,  the  thyroid,  and  the  kidney  (hypernephroma;  before 
concluding  that  a  growth  is  primary  in  the  bone. 


CANCER  89 

the  primary  lesion  is  insignificant,  and  it  may  be  remarkably  so.  I 
have  seen  an  epithelioma  no  larger  than  a  big  pin's  head,  between 
the  toes,  and  causing  no  trouble  there,  give  rise  to  an  enormous 
glandular  swelling  in  the  groin  ;  and  my  impression  is,  that  large 
glandular  tumours  with  a  small  primary  focus  are  more  frequently 
met  with  in  the  groin  and  on  the  foot  than  elsewhere  in  the  body. 

Chorion  Epithelioma  occurs  in  the  uterus  after  miscarriage  or 
labour,  and  occasionally  in  the  neighbourhood  of  the  testicle.  It 
consists  of  tissue-like  chorionic  epithelium,  and  is  early  disseminated 
by  the  blood,  secondary  growths  then  appearing  in  the  lung.  Its 
chief  surgical  interest  lies  in  the  fact  that,  after  extirpation  of  the 
primary  focus,  the  secondary  lung  infection  may  disappear,  and 
recovery  take  place. 

Spheroidal-celled  Carcinoma  is  the  ordinary  breast  cancer, 
and  occurs  also  in  the  stomach.  It  is  of  a  hard  (scirrhous)  and  of  a 
soft  (encephaloid)  variety.  The  softness  or  hardness  depends  upon 
less  or  more  fibrous  tissue  in  the  growth.  It  disseminates  by  tlw 
lymphatics,  and  under  certain  circumstances,  specially  attacks  and 
invades  the  lymphatic  vessels  in  anatomical  relation  with  the  skin. 
The  form  of  breast-cancer  known  as  cancer  en  cuirasse  arises  in  this 
way. 

Columnar-celled  Cancer  is  the  common  cancer  of  the  alimen- 
tary canal,  especially  of  the  rectum  and  colon.  It  disseminates  by 
the  lymphatics  chiefly,  but  occasionally  by  the  blood-stream. 

Diagnosis. 

Ulcer. — The  cancerous  ulcer  is  chiefly  characterized  by  the  fact 
that    it    shows    growth    in    excess    of  destruction.     This  is  usually 


Fig.  8i. — Diagram  of  Epitheliomatous  Ulcer. 

Growth  in  excess  of  destruction. 

(.-1)  Normal  skin.  (B)  Heapel-up  edges.  (C)  Ulcer  portion  of  destruction. 

most  marked  at  the  edges,   which    are   raised,   irregular,   nodulated, 
and  hard  {Fig.  82). 

Tumour. — Estimate    (i)    its    consistency,    (2)  surface,   (3)  edge, 
and  (4)  relation   to    surrounding  parts  : 


90 


CANCER 


The  cancerous  tumour  is  hard,  often  stony  hard ;  has  a  nodular 
surface  ;  an  edge  which  cannot  be  accurately  defined  all  round  ;  is 
fixed  to  the  tissues  in  which  it  lies,  and  invades  the  surrounding 
structures  and  lymphatic  glands. 

The  primary  growth  often  chooses  sites  in  which  the  vascular 
supply  is  best,  such  as  margin  of  lip ;  side  of  tongue ;  lesser  curva- 
ture of  stomach  ;  trigone  of  bladder  ;  and  still  more  often,  sites  at 
the  junction  of  two  different  surfaces — for  example,  skin  and  mucous 
membrane  of  lip  ;  pharynx  and  oesophagus  ;  oesophagus  and  stomach  ; 


Fig.  82. — Skin  Epithelioma. 
Notice  the  growth  in  excess  of  destruction. 


pylorus  and  duodenum  ;    ileum  and  colon  ;    and  rectum  and  anus  : 
but  the  most  frequent  site  of  all  is  the  skin. 

Symptoms  and  Signs. — It  cannot  be  too  strongly  emphasized 
that,  in  the  early  and  hopeful  stage  of  cancer,  there  is  no  pain  ;  there 
arc  no  alarming  symptoms  ;  and  the  physical  signs  are  not  likely  to 
be  characteristic.  The  symptoms  and  signs  usually  described,  and 
believed  to  be  characteristic  of  cancer,  are  the  symptoms  and  signs 
of  the  advanced  disease  ;  and  more  often  than  not  complicated  by 
septic  infection.  It  is  usual  to  get  a  history  from  patients  with 
cancer  of  the  discovery  of  an  ulcer,  or  of  a  lump,  months  before  there 


CANCER  91 

was  anv  discomfort,  or  other  recognized  occasion  for  alarm.  What 
s\Tnptom5  and  signs  should  cause  fear  of  the  possibility  of  cancer  ? 

Hcemorrhage. — Bleeding  from  the  stomach  ;  from  the  bowel  ; 
from  the  bladder  ;  from  the  kidneys  ;  from  the  uterus  ;  or  from  nasal 
polypi,  in  elderly  patients  always  suggests  cancer,  for  it  is  the  most 
probable  cause. 

Chronic  Irritations. — An  ulcer  on  the  tongue  which  does  not  heal 
within  ten  days  after  the  extraction  of  a  jagged  tooth,  or  which  does 
not  show  very  definite  signs  of  healing  within  ten  days  after  the 
administration  of  syphilitic  remedies,  should  be  regarded  as  cancerous, 
till  the  contrary  is  proved  by  microscopical  examination.  The  same 
rule  applies  to  ulcers  elsewhere,  and  it  is  specially  necessary  when  the 
patients  are  over  thirty-five  years  of  age. 

Leukoplakic  patches,  especially  when  irritable  or  showing  ulcera- 
tion, are,  if  not  cancerous  already,  the  precursors  of  cancer  ;  so  are 
irritable  or  ulcerated  warts  ;  cracked  and  irritated  burn  scars  ;  raised 
pigmented  rough  patches  on  the  skin  ;  and  sores  on  the  nipple  which 
resist  ordinary  treatment. 

The  Discovery  of  a  Tumour. — Every  tumour  which  does  not 
offer  a  definite  history,  and  present  s\-mptoms  and  signs  of  its  benignity, 
should  be  assumed  to  be  malignant  till  the  contrary  is  proved  by 
microscopic  examination.  This  rule  should  be  made  absolute  in 
regard  to  patients  over  thirty-five  years  of  age,  and  to  situations  in 
which  malignant  tumours  are  of  frequent  occurrence. 

For  example,  abdominal  tumours  in  adult  males,  eight  times  out 
of  ten  are  malignant.  It  should  also  apply  absolutely  for  certain 
varieties  of  tumours.  The  ordinary  '"benign"  adenomatous  polypus 
of  the  rectum  or  colon  should  always  be  suspected,  except  in  the 
case  of  a  child,  when  it  is  generally  simple.  I  have  watched  no 
adult  case  of  adenomatous  rectal  or  colon  polypi,  in  which  cancer 
of  the  bowel  failed  to  develop.  The  majority  of  breast  tumours  in 
elderly  women  are  cancers. 

The  danger  of  incising  the  tumour  to  sec  what  it  is.  must  be 
emphasized.  Such  a  course  may  lead  to  rapid  diffusion  of  a  malignant 
growth.  It  should  be  excised  along  with  an  area  of  healthy  surround- 
ing tissue  before  it  is  explored  ;  and  a  pathologist  should  be  ready  to 
offer  an  opinion  after  making  a  frozen  section,  so  that  an  immediate 
radical  operation  may  be  undertaken  if  necessar}'. 

The  Symptoms  of  Obstruction  from  stricture  in  the  hollow  viscera 
always  suggest  cancer. 

Twenty-nine  out  of  thirty  patients  who  have  difficulty  in 
swallowing  from  recently-developed  oesophageal  strictures,  have 
cancer.  A  smaller,  but  yet  a  large,  percentage  of  patients  with 
intestinal  obstruction  due  to  stricture  of  the  colon  or  rectum,  have 


92  CANCER 

cancer.  The  larger  number  of  pyloric  strictures,  developing  after 
forty  years  of  age.  are  due  to  cancer.  Jaundice,  resulting  from  chronic 
obstruction  of  the  bile-duct,  commencing  after  fort}',  is  also  generally 
due  to  cancer. 

Laboratory  tests  have  been  employed  for  the  discovery  of  cancer. 
One  of  the  most  promising  of  these  is  based  upon  the  fact  that  normal 
serum  does  not  haemolj'Se  normal  blood  corpuscles,  but  that  the 
corpuscles  of  a  cancer-patient  may  be  hsemolysed  by  normal  blood 
serum. 

None  of  the  suggested  tests  are  yet,  however,  sufhcienth^  perfect 
or  reliable.     We  await  with  hope  further  experimental  results. 

General  Condition. — Loss  of  weight,  anaemia,  and  the  appearance 
of  serious  illness,  presented  by  the  patient,  may  be  aids  to  diagnosis 
and  suggest  cancer.  The  so-called  cancerous  cachexia  appears  too 
late  to  be  of  much  practical  help. 

It  is  well  not  to  forget  that  the  general  appearance  of  a  patient, 
even  with  advanced  cancer,  may  be  that  of  rude  health. 

Prognosis. 

To  offer  a  general  practical  prognosis  is  easy.  Unless  the  cancer 
can  be  removed,  a  fatal  termination  is  inevitable. 

It  is  difficult,  or  impossible,  to  offer  an  opinion  of  any  value  as  to 
probable  duration. 

The  greatest  aid  is  to  be  found  in  a  knowledge  of  the  previous 
rate  of  growth,  and  the  extent  to  which  the  cancer  has  invaded  its 
surroundings  in  a  certain  time  ;  for,  as  a  rule,  the  same  degree  of 
malignancy  is  maintained  throughout. 

Cancer,  speaking  generally,  grows  with  great  rapidity  in  j'oung 
persons,  and  slowly  in  very  old  ones. 

The  harder  and  more  defined  the  growth,  the  better  the  prog- 
nosis. The  more  closely  cancer  resembles  an  inflammatory  swelling, 
the  worse  the  prognosis  ;  the  more  localized  the  tumour,  the  better 
it  is.  A  soft  growth  in  a  young  patient  is  likely  to  be  of  the  most 
malignant  type,  and  to  destroy  life  in  as  many  weeks  as  a  hard 
growth  requires  years  to  kill  an  old  person.  Fibrosis  is  the  cause  of 
hardness  ;    and  fibrosis  is  an  attempt  at  natural  cure. 

The  situation  of  the  growth  is  also  to  be  taken  into  account. 
Skin  cancers  generally  are  less  malignant  than  those  occurring  else- 
where ;  but  much  finer  distinctions  may  occasionally  be  drawn.  As 
a  rule,  cancer  of  the  lower  lip  possesses  a  low  malignancy,  while 
cancer  of  the  lip  at  the  angle  of  the  mouth  has  a  malignancy  as  high 
as  that  of  the  tongue. 

The  greater  part  of  a  prognosis  is  dependent  upon  complications 


CANCER 


93 


arising  in  the  course  of  a  case,  such  as  sepsis,  hsemorrhage,  and  the 
invasion  of  parts  important  to  hfe  ;  for  example,  hjngs,  stomach, 
larynx,  bladder,  intestine,  etc. 

Treatment. 

Excision  by  the  knife  still  holds  the  field  in  the  treatment  of 
cancer,  and  the  earlier  the  growth  can  be  removed  the  better.  It 
is,  at  present,  in  the  recognition  of  pre-cancerous  conditions,  with  a 


^"fcW^^^RSr 


Fii;.  83. — Diagram  to   Illustrate  Complete  Removal  of  Focus  of  Maligxaxt   Disease 
(Jamicson  and   Dobsoii). 

The  black  lines  indicate  the  limits  of  the  parts  excised.     (A)  Growth.     (B)  Superior  mesenteric  artery. 
(C)  Ileocolic  artery.     (D)  Middle  colic  artery. 


view  to  their  timely  removal,  that  the  possibilities  of  advance  in  the 
treatment  of  cancer  mainly  lie. 

Operation. — The  principles  to  be  borne  in  mind  for  the  proper 
performance  of  a  cancer  operation  are  simple  ;  their  execution  often 
demands  the  greatest  skill  in  surgery. 

Radical  Operation. — The  growth,  with  its  surrounding  lymphatic 
vessels,  should  be  widely  removed  in  one.  mass,  with  the  whole 
lymphatic  gland  area  into  which  it  drains  {Fig.  83). 


94  CANCER 

The  growth  ought  not  to  be  cut,  or  burst,  or  squeezed,  during  its 
removal,  lest  the  cancer-cells  be  driven  into  the  surrounding  tissues, 
and  thus  infect  them. 

Operations  on  these  lines  are  followed  by  such  increasing  success, 
that  in  favourable  cases  not  less  than  60  per  cent  are  permanently 
cured. 

Palliative  Operations. — So  long  as  cases  of  cancer  are  allowed  to 
drift  into  hopeless  conditions,  palliative  operations  will  require  to  be 
performed. 

Their  most  successful  application  has  been  for  the  relief  of 
mechanical  obstacles  produced  by  the  cancerous  growth;  e.g.,  trache- 
otomy in  laryngeal  obstruction,  gastrostomy  in  oesophageal  obstruc- 
tion, gastro-enterostomy  in  pyloric  obstruction,  lateral  anastomosis 
and  colostomy  in  intestinal  obstruction,  ovariotomy  for  pressure 
symptoms,  etc.  From  the  patient's  point  of  view,  the  most  satis- 
factory of  them  leave  no  visible  deformity  or  incapacity ;  for 
example,  intestinal  anastomosis  —  gastro  -  enterostomy.  Others — 
tracheotomy,  gastrostomy,  colostomy — should  not  be  done  until  the 
need  for  them  is  fully   apparent  to  the   patient   himself. 

A  second  satisfactory  use  of  palliative  operation  arises  from 
knowledge  of  the  fact  that  many  of  the  worst  symptoms  are  produced 
by  septic  infection  of  the  cancer  ;  and  that  if  the  sepsis  can  be 
removed  these  symptoms  will  disappear,  giving  much  relief  to  the 
patient,  and  prolonging  life. 

The  oldest  and  most  noted  example  of  this  is  afforded  by  excision 
of  the  tongue ;  but  the  excision  of  a  septic  gastric,  intestinal, 
uterine,  or  breast  growth  may  be  followed  by  equal  relief  ;  and  I 
think  these  operations  should  be  more  frequently  performed  than 
they  are,  because  it  may  be  accepted  as  a  rule,  that  growths  are  most 
active  in  the  primary  focus,  and  that  if  this  is  removed  there  is  a 
chance  of  slower  progress. 

Even  less  may  suffice.  One  young  woman  I  saw  with  inoperable 
cancer  of  the  cervix  uteri,  giving  rise  to  profuse  haemorrhage  and 
foetid  discharge  ;  and  who,  in  the  ordinary  course  of  events,  did  not 
appear  to  have  five  months'  to  live  ;  survived  in  comfort  for  five  years 
after  the  use  of  a  sharp  spoon  and  the  thermo-cautery,  with  frequent 
continued  antiseptic  dressings. 

Starvation  of  the  Growth. — Some  fair  results  have  followed  ligature 
and  excision  of  the  arteries  of  supply  in  inoperable  cases — linguals  in 
tongue  cancer  ;  external  carotids  in  jaw  cancer  ;  internal  iliacs  in 
cancer  of  the  cervix,  etc.  When  recurrent  haemorrhages  occur,  these 
operations  should  be  done. 

Electricity. — X-rays.  Some  cancers,  especially  those  of  the  skin, 
arc   curable   by  .r-rays.     The  most  favourable   arc   those  known  as 


SARCOMATA  95 

rodent  ulcers,  which  usually  occur  on  the  face.     The  pain,  discharge, 
and    ill-health    of    open,    septic,  inoperable    cancers    may   be    much 
benefited  by  the  use  of  jt-rays.     It  is  probable  that  their  use  after 
operation  is  an  aid  to  the  processes  which    favour   natural  cure  by. 
fibrosis. 

Fulguration. — Treatment  by  electric  currents  of  high  frequency 
and  tension,  and  radium  rays,  have  also  been  used  with  advantage  ; 
but  up  to  the  present  time  the  results  have,  on  the  whole,  been 
disappointing. 

Transfusion  of  i?/oorf.— Experiments  on  animals,  and  a  small 
amount  of  experience  derived  from  clinical  observation,  suggest  that 
blood  transfusion  may  be  useful  occasionally. 

General  Treatment. — No  one,  so  far  as  I  know,  has  yet  carried 
out  a  systematic  treatment  of  inoperable  cancer  on  the  same  lines  as 
that  which  has  proved  so  successful  in  tuberculosis.  Such  treatment 
could  scarcely  fail  to  be  a  valuable  aid  to  every  other  measure 
hitherto  mentioned,  and  would  probably  furnish  some  surprises. 
There  can  be  no  doubt  that  the  body  offers  considerable  resistance 
to  the  invasion  of  cancer,  for  a  natural  cure  has  resulted  in  cases 
where  the  diagnosis  was  based  upon  indisputable  evidence,  and  even 
when  the  circumstances  of  the  patients  were  such  that  no  help  at  all 
was  afforded  by  their  environment.  Patients  who  have  been  operated 
upon  for  cancer  should  live  as  much  as  possible  in  the  fresh  air  ; 
change  their  environment  if  they  can  ;  and  as  far  as  possible 
cultivate  a  philosophic  frame  of  mind.  In  only  two  cases  of  cancer 
of  the  breast  have  the  patients — both  relatively  young  women  with 
malignant  types  of  growth,  and  involvement  of  the  axillary  glands — 
implicitly  followed  my  directions  to  this  effect.  It  is  noteworthy 
that  they  are  both  alive  and  well,  the  first  operated  upon  eight, 
and  the  second  six,  years  ago. 

In  hopeless  cases  sufficient  doses  of  opium,  castor  oil,  and  wine 
(alcohol),  should  be  given  daily. 

Sarcomata. 

There  are,  in  typical  instances,  marked  clinical  distinctions 
between  cancer  and  sarcoma,  and  the  histological  character  of  each  is 
well  defined.  As  a  consequence  no  relationship,  except  their  malig- 
nant influence,  has  been  recognized  until  recently,  and  every  endeavour 
has  been  concentrated  on  finding  new  proofs  of  their  being  things 
apart.  In  addition  to  clinical  and  histological  evidence  that  the  one 
may  become  the  other,  there  is  now  experimental  proof  that  sarcoma 
may  be  grown  from  a  transplanted  cancer,  and  that  a  similar  exciting 
cause  is  common  to  both. 


96  SARCOMATA 

Histologicall3%  the  sarcomata  consist  of  tumours  composed  of 
embryonic  connective  tissue,  containing  abundant  blood-vessels  so 
thin-walled  that,  in  places,  the  blood  appears  to  be  in  contact  with 
the  cells  and  stroma  of  the  tumour. 

Predisposing  Causes. — 

Traumatism. — There  is  so  much  evidence  that  a  sarcoma  may 
develop  at  the  seat  of  a  recent  injury,  that,  remarkable  as  the 
conclusion  may  be,  it  is  evident  that  accident  is  a  predisposing  cause 
of  the  disease.  Desmoids. — One  of  the  most  striking  examples  of 
this  known  is  the  so-called  desmoid  tumour — histologically  a  fibro- 
sarcoma— of  the  abdominal  wall.  The  clinical  features  are  so  well 
marked  that  it  can  scarcely  be  mistaken  for  anything  else  when 
these  have  been  learned.  It  occurs  in  women  after  a  recent  preg- 
nancy (other  conditions  causing  great  stretching  and  strain  of  the 
abdominal  wall  are  said  to  have  preceded  it,  but  I  have  no  knowledge 
of  them),  as  a  hard  tumour,  most  frequently  in. the  rectus  muscle 
and  at  its  upper  part ;  less  often  in  one  of  the  obliques.  If  in  the 
rectus,  it  is  vertical,  and  elongated  in  the  direction  of  the  muscle  ; 
and  is  fixed  and  made  prominent  when  the  muscle  is  put  into 
action.  If  in  the  obliques,  it  is  usually  found  as  an  elongated 
rounded  swelling,  lying  obliquely  above  Poupart's  ligament.  If 
freely  removed,  it  usually  does  not  recur,  but  the  freest  incision 
cannot  ensure  this.  One  of  my  patients  died  through  local  recurrence 
after  four  extensive  operations  ;  others  have  returned  for  a  second, 
operation  when  the  first  was  too  limited. 

Too  many  patients  with  bone  sarcomata  date  the  appearance  of 
a  tumour  after  injury  to  permit  of  coincidence  as  the  explanation. 

Age  and  Sex. — Sarcoma  is  attached  to  no  particular  period  of 
life,  but  attacks  persons  of  any  age,  or  of  either  sex. 

Simple  Tumours. — Certain  tumours,  generally  regarded  as  simple, 
predispose  to  the  development  of  sarcoma.  There  is  a  condition  of 
multiple,  soft,  fibrous  skin  tumours  described  clinically  as  molluscum 
fibrosum.  Dissection  shows  that  it  is  associated  with  similar  en- 
largements on  the  nerves  (neuro-fibromatosis).  Patients  with  this 
disease  so  often  develop  sarcomata  of  the  nerve  trunks,  that  it  seems 
probable  that  all  of  them,  in  the  natural  course  of  events,  will  die  of 
sarcoma,  just  as  certainly  as  patients  with  multiple  polypi  in  the 
rectum  and  colon  will  die  of  cancer. 

Scars. — Some  scars,  especially  those  consequent  upon  burns, 
or  the  results  of  operation  for  tubercle,  may  develop  into  tumours 
called  keloid,  histologically  often  fibro-sarcomata.  After  reaching  a 
certain  size  keloids  grow  no  larger,  remain  unchanged  for  many  years, 
and  then  tend  to  atrophy.     These  tumours  so  often  recur  locally, 


SARCOMATA  97 

and  with  increased  malignity  after  excision,  that  no  attempt  should 
be  made  to  remove  them  by  operation.  One  patient  consulted  me 
with  a  stationary  scar  keloid  on  the  abdominal  wall,  not  larger  than 
a  shilling  piece.  The  burning  irritation  of  it  made  her  desire  its 
removal  ;  but  I  refused  to  do  any  operation.  Ten  years  later  I  saw 
her  again.  She  had  a  keloid  on  her  abdominal  wall  not  less  in  cir- 
cumference than  a  saucer,  after  six  operations  for  the  removal  of 
the  growth.  She  had  attempted  to  commit  suicide,  and  was  still 
anxious  to  have  a  further  attempt  made  to  excise  the  tumour. 

The  tubercle  bacillus  and  septic  organisms  have  been  found  in  the 
keloid  following  operations,  and  occasionally  a  small  tuberculous 
focus  shows  itself  at  one  or  other  part  of  the  scar  following  operation 
for  tubercle,  suggesting  that  a  modified  septic  or  tuberculous  infection 
may  cause  keloid.  To  get  over  this  difficulty  it  has  been  proposed 
to  call  the  scar  growth  associated  with  sepsis  and  tubercle,  pseudo- 
keloid,  but  this  would  be  of  doubtful  utility.  There  is,  however, 
one  point  worth  remembering  in  connection  with  this  variety 
of  keloid.  It  is  that  Roentgen  ra3^s  may  very  rapidly  cause  its 
disappearance. 

;  Epulis. — This  tumour  may  occur  in  connection  with  the  alveolus 
of  a  septic  tooth.  One  variety  has  the  histological  and  clinical 
characters  of  a  sarcoma,  and  tends  to  recur  after  removal. 

The  Exciting  Cause  of  sarcomata,  like  that  of  cancer,  is  un- 
known. 

Commencement. — Like  cancer,  it  rarely  begins  otherwise  than  as 
a  single  local  lesion  ;  but,  unlike  cancer,  it  does  not  usually  dissemi- 
nate by  the  lymphatics,  or  infect  the  glands. 

Method  of  Spread. — The  primary  lesion  is  a  tumour  which  dis- 
seminates through  the  veins  ;  and  secondary  deposits  first  infect  that 
viscus,  the  capillaries  of  which  first  receive  blood  from  the  infected 
source.  The  text-book  reason  offered  for  this  blood-distribution  is  the 
much  more  close., relation  of  the  tumour  tissue  to  the  blood-vessels 
in  sarcoma  than  in  cancer.  But  it  has  been  proved  abundantly  by 
post-mortem  and  microscopical  research,  that  cancer-cells  are  con- 
stantly found  in  the  lung  capillaries  of  persons  who  have  died  from 
cancer,  showing  that  the  difficulties  which  cancer  encounters  in 
effecting  an  entrance  to  the  blood-vessels  have  been  overcome.  That 
secondary  deposits  in  the  lung  are  as  rare  in  cancer  as  they  are 
common  in  sarcoma  shows  that,  for  some  reason,  cancer  has  a 
greater  difficulty  than  sarcoma  in  growing  in  the  lung  capillaries. 
What  is  the  explanation  ?  It  is  known  that  cancer-cells  are  destroyed 
by  the  blood,  the  stages  through  which  they  pass  in  their  slaughter 
and  disintegration  having  been  carefully  observed  in  thrombi  from 
the  lung  capillaries.     The  same  is  not  known  of  sarcoma  cells.     It 

7 


98  SARCOMATA 

ma}'  be,  though  it  seems  improbable,  that  sarcoma  cells  resist 
destruction  by  the  blood.  It  appears  to  be  more  probable  that 
infection  b}'  embolism,  and  its  more  frequent  occurrence  in  sarcoma, 
is  the  explanation.  Doubtless  a  sarcomatous  embolus,  if  small 
enough,  may  be  totally  destroyed  in  the  blood ;  but  if  sufficiently 
large  to  survive,  it  could  form  an  adhesion  and  become  a  tumour  as 
surely  as,  and  in  a  similar  way  to,  one  experimentally  grafted.  When 
an  embolism  of  microscopic  size  is  arrested  in  a  lung  blood-vessel,  and 
is  not  large  enough  to  cause  immediate  death,  an  infarct  results,  and 
the  ordinary  clinical  evidences  of  embolic  infarction  should  be  observ- 
able if  this  explanation  be  the  correct  one.  They  are  a  stitch  in  the 
side  and  a  catch  in  the  breath,  followed  b}^  cough,  blood-spitting,  and 
a  patch  of  pleural  friction.     I  have  seen  all  of  these  occur  in  sarcoma. 

Secondary  deposits,  as  in  cases  of  cancer,  resemble  the  primary 
focus ;  for  instance,  in  certain  osteo-chondro-sarcomata,  the  growths 
in  the  lungs  contain  bone  or  cartilage. 

There  are  notable  exceptions  to  the  rule  that  sarcomata  do  not 
involve  the  lymphatic  glands,  or  spread  by  the  lymphatic  vessels. 
One  of  the  most  malignant  of  growths  is  called  melanotic 
sarcoma.  It  starts  usually  as  an  insignificant-looking,  painless, 
subcutaneous  nodule,  which  for  a  time  grows  slowty  and  causes  to 
the  uninitiated  no  alarm.  After  a  time,  the  nearest  glands  become 
involved,  then  wider  and  wider  areas  under  the  skin  ;  and  finally, 
if  the  patient  lives  long  enough,  melanotic  growths  develop  in  every 
part  of  the  body.  The  earliest  and  widest  excision  often  fails  to 
arrest  this  serious  disease.*  The  foot  appears  to  be  a  favourite  site 
for  melanotic  sarcoma. 

Another  sarcoma  (lympho-sarcoma)  finds  its  primary  focus  in  a 
lymphatic  gland  and,  like  cancer,  extends  to  the  h^mphatics.  The 
tonsil  and  the  testicle  are  also  notable  exceptions,  for  sarcoma 
primary  in  them  attacks  the  nearest  lymphatic  glands. 

It  is  noteworthy  that  the  tonsil,  lymphatic  glands,  and  testicle 
all  have  a  definite  capsule.  Is  it  possible  that  this  may  prevent 
pieces  of  growth  from  escaping  as  emboli  into  the  larger  veins  ? 

Classification. 

Sarcomata  are  classified  according  to  the  anatomical  character 
of  the  cells  and  of  the  stroma.  From  their  cellular  characteristics 
they  are  known  as  small  and  large  round-celled,  small  and  large 
spindle-celled,  mixed-celled,  lymphangio,  and  giant-celled  sarcomata. 


*  In  a  rare  case  of  melanotic  cancer  of  the  fore  part  of  the  foot  which  I  saw, 
Syme's  amputation,  without  removal  of  glands,  effected  a  cure,  so  that  melanotic 
cancer  may  not  possess  the  same  malignancy  ? 


SARCOMATA 


99 


From  the  characteristics  of  the  stroma  they  are  described  as  chondro- 
osteo,  petrifying,  and  myo-sarcomata.  When  containing  pigment, 
they  are  called  melanotic  sarcomata  and  chloromata. 


Fi^.  84. — ■•Periosteal"  Sarcoma  of  the  Ulna. 


Diagnosis. 

The  diagnosis  of  a  bone  sarcoma  may  be  made  definite  by 
;t-rays  {Fig.  84). 

A  tumour  which  has  most  of  the  signs  of  but  is  not  an 
aneurysm,  is  a  sarcoma. 


100  SARCOMATA 

The  discovery  of  a  recent  tumour,  especiall}^  if  connected  with 
skin,  fascia,  or  bone,  should  suggest  the  possibility  of  sarcoma.  So 
should  soft  cystic  areas  in  a  solid  growth  (cystic  degeneration  is 
common  in  sarcoma),  sudden  increases  in  size  (haemorrhage  into  it), 
or  egg-shell  crackling. 

The  black  colour  of  a  melanotic  sarcoma,  or  the  green  colour  of 
a  chloroma,  make  their  diagnosis  relatively  eas\-. 

All  large  solid,  and  all  large  bone,  tumours  of  recent  growth 
are  sarcomata. 

■Symptoms  and  Signs. 

As  in  cancer,  so  in  sarcoma,  there  are  no  pathognomonic 
symptoms  or  signs.  The  tumour  has  consequently  been  mistaken 
for  all  of  the  inflammator}'  swellings ;  for  the  callus  of  fracture  ; 
for  a  benign  growth  ;  and  for  cancer.  There  is  usually  pain,  ranging 
from  discomfort  to  agony,  according  to  the  degree  of  tension ;  con- 
sequentl3%  the  rapidly  growing  endosteal  tumours  are  those  in  which 
severe  pain  is  a  marked  feature.  A  sudden  increase  of  the  pain, 
attended  by  enlargement  of  the  growth,  suggests  haemorrhage  into  it, 
and  a  sarcoma.  Multiple  soft  spots  suggest  c^'stic  degeneration,  and 
this  is  very  usual  in  sarcoma.  As  a  test,  this  fact  is  most  useful 
in  distinguishing  between  a  Brodie's  bone  abscess  and  a  sarcoma, 
for  in  abscess  the  soft  spot  is  single.  If  a  joint  swelling  resembles 
a  tuberculous  arthritis,  and  has,  throughout  its  development,  been 
accompanied  by  extraordinary  pain,  it  is  probabh^  the  result  of  a 
bone  sarcoma  which  has  eroded  a  passage  into  the  joint  {Fig.  85). 

Prognosis. 

This  depends  upon  the  clinical  history,  and  upon  microscopical 
evidence. 

In  the  soft,  rapidly-growing  tumours  of  young  persons  the 
prognosis  is  worst.  Lung  metastasis  occurs  within  a  few  weeks  of 
the  discovery  of  the  growth,  and  death  shortly  follows. 

Slow-growing  hard  tumours  may  take  3'ears  to  run  their  course, 
which  means  that  the  active  cellular  elements  are  kept  in  check  by 
surrounding  fibrosis  or  ossification. 

Microscopically,  help  may  be  derived  from  a  knowledge  of  the 
character  of  both  cells  and  stroma.  The  soft,  most  malignant 
growths,  are  composed  chiefly  of  round  cells ;  the  more  highly 
developed,  and  the  less  resembling  embryonic  tissue  the  cells  are,  the 
better  the  prognosis.  A  dense,  large  fibrous,  osseous,  or  cartilaginouf 
stroma,  with  few  cells,  means  slow  development. 

The  pigmented  sarcomata  run  a  specially  malign  course. 


SARCOMATA 


101 


Fig.  85. — Bone  Sarcoma  ixvading  the  Knee  Joint. 


102  SARCOMATA 


Treatment. 


Wide  and  earl}"  excision  is  the  treatment  for  sarcoma,  when  it 
can  be  carried  out  before  secondarj'  deposits  have  developed.  These 
occur  so  early  that  in  the  more  rapidly-growing  tumours  the  most 
complete  operation  is  often  a  faiku'e.  It  is  wrong  to  continue  to 
amputate  entire  extremities  on  the  off  chance  of  curing  rapidly- 
growing  sarcomata  when  past  records  show,  as  they  do,  that  chance 
to  be  so  small.  Other  less  destructive  means  have  been  tried,  and 
even  now  their  showing  is  better  than  those  of  so-called  radical 
operations.  One  method  is  to  remove  the  interior  of  the  growth  as 
far  as  convenient,  to  swab  the  raw  surface  with  pure  carbolic  acid, 
followed,  after  half  a  minute  by  alcohol,  to  neutralize  the  acid,  and 
to  pack  the  cavity.  In  a  few  days,  when  all  tendencj'  to  bleed  has 
disappeared,  a  course  of  .r-ray  applications  to  the  remains  of  the 
tumour  is  commenced,  and  continued  for  some  months  after  all 
growth  has  disappeared. 

Another  method  is  based  upon  the  observation  that  an  attack 
of  erysipelas  in  cases  of  sarcoma  has  occasionally  been  followed  by 
disappearance  of  the  tumour.  Dr.  Coley,  of  New  York,  introduced 
a  fluid  consisting  of  the  mixed  toxins  of  the  streptococcus  of  erysipelas 
and  of  the  bacillus  prodigiosus  for  use  in  these  cases,  and  in  his  hands 
the  results  have  been  so  remarkable  as  to  call  for  more  attention  than 
they  have  even  yet  received.  With  proper  care,  and  in  suitable 
doses,  it  has  been  proved  that  the  use  of  these  remedies  is  safe,  and 
it  has  also  been  placed  above  all  doubt  that  a  fair  percentage  of 
inoperable  cases  have  been  permanently  cured  b}^  them.  One  patient 
under  my  own  care  has  for  three  years  remained  cured  of  an  inoperable 
recurrence,  after  two  operations  for  a  rapidlj'-growing  sarcoma  of 
the  groin.  Those  who  refuse  to  accept  such  evidence  as  has  been 
offered  in  support  of  this  treatment,  fail  in  their  duty  to  these,  at 
present,  otherwise  hopeless  cases.  M}^  present  view  is  that  jv-rays 
and  Coley  should  be  used  conjointly. 

Experimental  work  offers  promise  of  help  in  the  treatment  of 
sarcoma.  Certain  dogs  are  immune  to  sarcoma.  Other  dogs  succumb 
to  it  readily.  If  a  dog  affected  with  sarcoma  is  bled  as  far  as  it  is 
possible  to  do  it,  and  is  then  restored  by  the  transfusion  of  blood 
from  an  immune  dog,  the  growth  of  the  sarcomatous  dog  disappears.* 
There  is,  of  course,  proof  required  that  dog  sarcoma  and  human 
sarcoma  are  similar,  though  there  is  strong  evidence,  such  as  their 
histology,  and  method  of  dissemination,  that  they  are. 


Practical  Medicine  Series,  "  General  Surgery,"   1909,  Murphy. 


H.^MOPHILIA  103 


H/EMOPHILIA. 


The  popular  name  for  a  haemophiliac  is  "  a  bleeder,"  which  is 
sufficiently  expressive.  The  fully- developed  example  of  this  con- 
dition is  well-known.  He  is  always  in  typical  cases  a  male ;  with  the 
tendency  to  bleed  from  small  cuts,  abrasions  or  tooth  extraction,  so 
seriously  and  continuously  as  to  endanger  his  life  ;  with  a  tendency  to 
extensive  ecchymosis  after  the  slightest  bruising  ;  with  changes  in 
his  joints  resembling  those  produced  by  osteo-arthritis,  the  result  of 
repeated  intra-articular  haemorrhages  ;  and  possibly  hard  nodules  or 
lumps  in  his  muscles  from  old  blood  extravasations.  He  usually 
can  give  a  family  history  demonstrating  hereditary  tendency,  handed 
down  from  the  father  and  through  his  daughter,  who  escapes,  to  her 
sons. 

In  the  worst  cases,  death  occurs  in  youth  as  a  consequence  of 
the  strong  tendency  to  bleed.  Those  who  survive  the  early 
years,  tend  to  improve  as  they  become  older.  The  mildest  cases 
are  those  with  only  an  exceptional  tendency  to  bleed,  and  it  is 
difficult  to  say  in  this  connection  where  physiology  ends  and 
pathology  begins. 

Every  surgeon  must  have  observed  the  different  tendency  to 
bleed  exhibited  in  operations  by  ordinary  individuals.  Diffuse 
capillary  oozing  and  active  haemorrhage  from  small  vessels  is  not 
uncommonly  noticed  after  making  the  skin  incision  in  some  persons, 
whilst  in  others  scarcely  a  drop  of  blood  follows  an  incision  made  in 
the  same  position.  The  truth  is,  that  the  tendency  to  loss  of  blood 
depends  more  upon  the  individual  than  upon  any  other  factor.  It 
is  at  least  true  to  say  that,  whilst  one  person  may  bleed  to  death 
from  a  very  small  artery,  another  can  recover  from  a  wound  of  any 
except  the  largest. 

Another  individual  peculiarity  is,  that  the  tendency  to  bleeding 
in  some  is  specially  localized  to  a  particular  part  or  organ.  One 
person  will  readily  bleed  from  the  nose ;  another  from  the  throat  or 
the  stomach,  the  rectum,  the  bladder,  or  the  uterus  ;  and,  though 
it  is  true  that  skilled  examination  can  usually  offer  some  definite 
explanation,  the  pathological  condition  discovered  does  not  provide 
the  whole  reason.  Haemorrhoids  will  never  bleed,  or  only  to  a  trifling 
extent,  in  some  individuals ;  the  same  lesion  in  others  is  accompanied 
by  profuse  and  repeated  haemorrhages.  A  similar  statement  applies 
to  stomach,  bladder,  uterine,  and  other  diseases,  in  all  of  which  not 
the  gross  pathology  alone  counts,  but  also  the  individual  tendencies. 
It  may  be  as  important  to  know  these  as  to  know  how  blood  loss  has 
been  tolerated  on  previous  occasions. 


104  WOUNDS 


WOUNDS. 


An  injiuy  which  produces  no  breach  in  the  continuity  of  the 
skin  is  not  described  in  surgical  books  as  a  wound,  however  much 
destruction  of  the  deeper  tissues  may  be  caused  by  it.  This  empha- 
sizes, perhaps  better  than  anything  else,  the  importance  of  the  skin 
as  the  chief  protection  to  the  body. 

Such  deep  wounds,  with  an  unbroken  skin,  are  called  contusions, 
bruises,  or  simple  fractures,  and  the  chief  evidence  of  them  is 
afforded  by  the  signs  of  deep  haemorrhage.  The  lacerated  blood- 
vessels usually  bleed  into  the  surrounding  cellular  tissue,  and  the 
blood  travels  in  the  direction  of  least  resistance.  When  it  arrives 
at  the  skin,  producing  the  characteristic  blue-black  appearance,  it  is 
called  an  ecchymosis.  When  it  escapes  into  a  closed  cavity,  for 
example,  the  tunica  vaginalis,  it  is  described  as  a  hcematocele. 
When,  for  any  reason,  it  is  localized,  it  is  said  to  be  a  hcBtnatoma  ; 
and  later  on,  this  may  form  only  a  cyst,  the  corpuscles  and  all  except 
some  clear  serum,  having  been  absorbed.  Apart  from  the  severity  of 
the  injury,  it  is  safe  to  say  that  deep  haemorrhage  is  the  only,  and  a 
rare,  danger  of  this  variety  of  wound  ;  for  suppuration,  unless  infec- 
tion be  allowed  to  enter  by  insufficient  care  of  the  skin,  or  be  intro- 
duced by  careless  instrumental  exploration,  is  extremely  uncommon. 
The  amount,  or  the  position,  of  a  deep  haemorrhage,  may  be  an  aid 
to  diagnosis  ;  thus,  a  large  diffuse  subcutaneous  haemorrhage  in  the 
arm  or  the  leg  is  strong  evidence,  even  when  other  ordinary  signs 
are  absent,  in  favour  of  a  fracture,  because  the  vessels  of  the  bone 
being  fixed  in  bony  canals,  can  neither  contract  nor  retract,  and  the 
veins  are  relatively  large,  have  no  valves,  and  bleeding  from  them  is 
steady  and  continuous.  The  fan-shaped  subconjunctival  haemorrhage 
which  occurs  over  the  external  rectus  muscle  of  the  eye  a  day  or 
two  after  a  head  injury,  is  strong  evidence  in  favour  of  a  fracture  of 
the  anterior  fossa  of  the  skull. 

It  was  the  extraordinary  freedom  from  danger  of  such  injuries, 
and  especially  a  comparison  of  the  results  in  simple  and  compound 
fractures,  that  led  to  the  introduction  of  the  subcutaneous  methods 
of  operation,  some  of  which  (tenotomy,  osteotomy)  still  continue  to 
be  used. 

The  treatment  of  such  injuries  is  to  endeavour,  so  far  as 
possible,  to  limit  blood  extravasation  ;  and  when  this  has  occurred,  to 
help  the  absorption  of  it.  The  first  indication  is  met  by  the  use  of 
continuous  elastic  compression,  best  made  by  the  application  of 
abundance  of  cotton-wool,  and  over  this  a  firm  bandage  ;  the  second, 
by  the  same  measure  aided  by  massage  to  hasten  absorption. 

The    text-book    division   of    wounds    is    into   incised,    lacerated 


WOUNDS  105 

and  contused,  punctured,  arid  gunshot.  The  characters  of  the 
gunshot  might  be  summarized  as  a  mixture  of  all  the  other  varieties. 
Healing  is  described  as  occurring  by  first  intention  ;  by  second  inten- 
tion ;  by  the  union  of  two  opposed  granulating  surfaces  ;  by  granula- 
tion ;  scabbing  ;  under  a  blood-clot,  etc. 

The  most  useful  classification  of  wounds  divides  them  into  two 
varieties,  the  aseptic  and  the  septic ;  and  the  important  thing  to 
remember  concerning  healing  is,  that  whether  a  wound  is  to  unite 
either  with  a  minimum  of  pain,  with  no  more  loss  or  destruction  of 
tissue  than  has  resulted  directly  from  the  injury,  and  in  the  shortest 
space  of  time  ;  or  whether,  after  a  serious  and  painful  illness  arising 
from  inflammation  and  suppuration  in  the  wound  ;  fever — the  result 
of  these — and  a  prolonged  and  unsatisfactory  treatment ;  depends 
nearly  altogether  upon  the  exclusion  of  organisms  from,  or  their 
admission  to,  the  wound. 

An  Aseptic  Wound,  the  surfaces  of  which  can  be  brought  satis- 
factorily together,  may  be  relied  upon  to  heal  by  first  intention.  If 
sloughing  or  gangrene  occur  as  the  result  of  the  injury  ;  if  the  surfaces 
are  forced  apart  by  accumulation  of  blood  inside  ;  or  if  unrest  does  not 
allow  of  immediate  union,  the  granulations  covering  the  surfaces  of 
the  wound  secrete  no  pus  ;  there  is  no  pain  or  serious  constitutional 
disturbance,  and  healing  steadily  progresses  in  spite  of  every  drawback. 

Treatment. 

As  the  most  perfect  healing  occurs  in  subcutaneous  wounds, 
consideration  of  the  conditions  peculiar  to  them  should  serve  as 
a  useful  guide  to  satisfactory  wound  treatment,  assuming  that  the 
surgeon  has  complete  control,  as  he  should  have  in  an  operation 
case. 

In  such   a  subcutaneous  wound  : 

1.  Micro-organisms,  chemical  irritants,  and  air  are  excluded. 

2.  Continuous  pressure  is  exercised  on  the  wounded  structures 
by  the  undivided  elastic  skin. 

3.  There  is  a  minimum  of  interference  with  the  wounded  struc- 
tures.    No  dressings,  no  drainage  tubes,  no  sutures,  no  ligatures. 

4.  Heat  is  retained  by  the  unbroken  superficial  parts. 

How  are  the  entrance  of  micro-organisms  and  the  risks  of  wound 
infection  to  he  prevented  ? 

Organisms  may  be  conveyed  into  the  wound  by  the  hands  of 
the  surgeon  or  his  assistants,  the  skin  of  the  patient,  talking  over 
the  wound,  instruments,  sponges,  ligatures  and  sutures,  clothing, 
dressings,    and    the    air.       Their    entrance    is    to   be    prevented    by 


106  WOUNDS 

unremitting  scrupulous  care,  and  conscientious  attention  to  every 
detail  of  this  knowledge  ;  and  nothing  is  more  certain  than  that  the 
more  perfect  the  methods  of  carrying  these  details  into  practice,  the 
more  nearl}^  approaching  perfection  results  will  be. 

In  the  operating  theatres  there  are  daily  opportunities  for 
observing  how  these  measures  may  be  effected  ;  how  the  wound  is 
protected  from  the  hands  of  the  surgeon,  his  assistants,  and  nurses, 
by  prolonged  cleansing  and  disinfection,  and  the  wearing  of  india- 
rubber  gloves  ;  how  the  patient's  skin  is  purified,  and  the  wound 
protected  from  it  ;  how  the  effects  of  talking  into  the  wound  are 
avoided  ;  how  instruments,  ligatures,  sutures,  sponges,  dressings, 
etc.,  are  sterilized  in  elaborate  sterilizers  and  by  antiseptics  ;  how 
air  contamination  is  avoided  by  means  of  specially-constructed 
theatres,  the  wearing  of  sterilized  garments  by  every  one,  and  a  moist 
atmosphere  ;  and  one  is  apt  to  think  that,  without  any  or  all  of 
these  things,  good  surgery  is  impossible. 

This  would  be  wrong.  Every  measure  mentioned  is  an  aid  to 
the  achievement  of  ideal  heahng,  and  that  should  be  the  aim  of  every 
surgeon ;  but  not  one  of  them  is  essential.  Lister's  work  has  proved 
for  all  time,  that  safe  and  successful  surgery  requires  no  complicated 
or  elaborate  technique,  no  costly  apparatus,  no  special  buildings,  if 
the  principles  of  wound  treatment  discovered  by  him — how  to  keep 
away  bacterial  infection — are  remembered,  and  intelligently  acted 
upon.  The  only  special  requirements  are  :  soft  soap,  a  hard  new 
nail-brush,  washing  soda,  turpentine,  methylated  spirit,  a  very  large 
pan,  a  good  fire,  clean  basins,  towels,  abundant  water,  carbolic  acid, 
and  corrosive  sublimate  tabloids.  The  cleansing  of  patient,  operator, 
and  assistants,  is  then  proceeded  with. 

The  Skin  of  the  Patient,  covering  the  area  to  be  operated  on, 
is  washed  thoroughly  with  carbolic  acid  lotion  (1-20)  for  five  minutes  ; 
and  during  other  preparations,  a  towel  wrung  out  of  the  same  lotion 
is  left  lying  on  it. 

The  Hands  and  Arms  of  operator,  assistants,  and  nurses, 
are  cleansed,  first  by  washing  not  less  than  five  minutes  with  soft  soap 
and  hot  water  (frequently  changed),  and  a  nail-brush,  special  care 
being  taken  to  see  that  nails  are  short  and  clean  ;  then  comes  rubbing 
with  turpentine,  and  finally  with  methylated  spirit,  the  nails  and  their 
roots  again  receiving  particular  attention.  The  last  stage  in  the 
purification  consists  in  soaking  the  hands  and  arms  in  i-iooo  corrosive 
subhmate  lotion. 

Meanwhile  all  the  instruments,  dressings,  towels,  'mops,  etc., 
required,  have  been  placed  in  a  pan  filled  with  a  solution  of 
soda  in  water  (one  heaped  tablespoonful  to  each  quart),  and 
boiled  for   ten  minutes.     If   nothing  else   is   available    for    ligatures 


WOUNDS  107 

and  sutures,  linen  thread,  or  silk,  should  be  added  to  the  contents 
of  the  pan. 

A  flat  dish,  thoroughly  washed,  and  covered  by  a  towel  soaked  in 
1-20  carbolic  lotion,  is  to  be  used  as  an  instrument  tray;  scalded 
basins  charged  with  carbolic  and  corrosive  sublimate  lotions,  should 
be  in  readiness  ;  and  the  area  to  be  operated  upon  is  surrounded 
and  isolated,  by  sheets  or  towels  wrung  out  of  1-20  carbolic  lotion. 

Before  commencing,  all  hands  and  arms  engaged  are  soaked 
again  in  i-iooo  corrosive  sublimate  lotion,  which  is  to  be  washed 
off  with  1-10,000  sublimate  lotion,  before  making  a  wound.  The 
reason  for  this  is  that  all  germicides  are  irritants,  more  or  less  vicious, 
and  in  imitating  healing  of  the  subcutaneous  wound,  the  endeavour 
should  be  to  avoid,  as  far  as  possible,  contact  of  raw  surfaces  with  them. 

Boiled  towels,  in  an  emergency,  serve  very  well  as  mops  during 
the  operation,  and  as  a  dressing  after  it.  It  is  a  good  precaution  to 
wring  out  of  methylated  spirit  the  towel  next  to  the  wound  and  used 
as  a  dressing. 

If,  during  the  progress  of  the  operation,  any  of  the  hands  engaged 
in  it  touch  what  is  unsterilized,  that  hand  must  be  regarded  as  unclean 
till  a  further  process  of  purification  has  been  gone  through.  The 
same  rule  applies  to  instruments,  or  anything  else  in  connection  with 
the  wound.  A  single  slip ;  a  moment  of  forgetfulness  ;  may  make 
the  difference  between  failure  and  success. 

The  dangers  of  air  infection,  though  not  to  be  disregarded,  are 
slight.  Movements  in  a  dry,  dusty  room  disturb  the  atmosphere, 
and  floating  particles  of  dust  can  carry  organisms  into  the  wound. 
Our  floors  are  constantly  sprinkled  with  corrosive  lotion  to  prevent 
this. 

The  danger  of  talking  into  wounds  is  a  very  real  one,  for 
during  conversation  particles  of  saliva  are  ejected  with  considerable 
force,  and  carry  with  them  the  mouth  organisms.  If  masks  are  not 
worn,  talking  should  be  avoided  as  far  as  possible,  and  mouths 
should  be  rinsed  with  antiseptics  before  each  operation. 

How  is  the  continuous  elastic  pressure  of  the  undivided  skin  of  the 
suhcutaneous  wound  to  he  imitated  ? 

By    careful    Suture    of    the    skin,   and    skilful    Dressings. 

The  importance  of  properly  applied  pressure  in  surgery  can 
scarcely  be  exaggerated.  Firm  and  careful  Bandaging  over  abun- 
dance of  cotton-wool  brings  the  wound  surfaces  into  apposition,  and 
hastens  healing  ;  it  prevents  exudation  ;  lessens  the  need  for  drainage  ; 
and,  by  securing  rest,  minimises  pain. 

Hoiv  is  the  minimum  of  interference  with  the  wounded  structures  of 
the  subcutaneous  wound  to  he  imitated? 


108  WOUNDS 

By  manipulations,  as  gentle  as  possible  ;  by  the  avoidance  of 
sluicing  with  antiseptics,  the  inclusion  of  large  portions  of  tissue  in 
ligatures,  the  use  of  ligatures  when  torsion  will  suffice,  the  use  of 
unabsorbable  when  absorbable  ligatures  could  be  substituted,  or  the 
contact  of  drainage  tubes  or  gauze  when  either  is  unnecessary. 

How  is  Heat  to  he  retained  ? 

Insufficient  attention  has  been  bestowed  upon  the  part  played  by 
heat  in  wound  healing.  Where  do  wounds  heal  as  the\^  do  in  the 
peritoneal  cavity  ?  In  the  mouth,  wounds  labour  under  great  disad- 
vantages. The}^  are  necessarily  infected,  and  constantly  irritated, 
by  foreign  bodies  and  unrest  ;  but,  because  of  the  heat  and 
moisture,  they  heal  rapidly.  The  same  moist  heat,  and  elastic 
pressure,  explain  the  success  of  Martin's  bandage  in  the  treatment 
of  leg  ulcers.  The  large  wool-dressing  advised  supplies  this  require- 
ment for  our  wounds. 

Summary. — In  an  operation  wound  the  aims  of  the  surgeon 
are  : — 

The  exclusion  of  organisms. 

The  infliction  of  as  little  damage  to  the  tissues  as  possible. 

The  support  of  continuous  elastic  pressure. 

The  retention  of  heat. 

A  wound  on  which  these  principles  have  been  carried  out  should 
heal  under  a  single  dressing  and  without  pain  or  constitutional 
disturbance. 

A  more  severe  test  of  the  truth  of  all  this  could  scarcely  be  offered 
than  the  application  of  the  method  of  amputation  through  the  thigh 
for  diabetic  gangrene. 

The  last  two  patients  on  whom  I  have  operated  w  ere  : — 

C.^SE  4. — Female,  aged  67,  admitted  to  a  private  hospital  with  septic 
diabetic  gangrene  of  all  the  toes  and  spreading  on  to  the  dorsum  of  her  left 
foot.  Her  general  condition  was  very  poor,  as  she  was  worn  out  with  pain, 
loss  of  rest,  and  septic  absorption.  In  addition  to  sugar,  her  urine  con- 
tained albumin,  and  she  was  nearly  blind  from  albuminuric  retinitis. 

Operation. — April  18,  1910.  ^^'ound  dressed  for  first  time  April  30, 
1910  (twelve  days),  and  found  to  be  entirely  healed.  Temperature  and 
pulse  normal  the  whole  time. 

Case  5. — Female,  aged  60,  admitted  to  the  Royal  Mctoria  Infirmary 
for  diabetic  gangrene,  involving  the  fourth  toe  and  the  sole  of  her  left  foot. 

Operation. — August  25,  igio.  Wound  dressed  for  the  second  time  on 
September  9,  1910  (eleven  days).  It  was  completely  healed.  (The  day 
after  operation  her  morning  temperature  was  101-5,  though  she  made  no 
complaint,  and  the  leg  was  comfortable.  Ne.xt  day  it  was  normal,  and 
remained  so  for  four  days.  Then,  as  it  rose  to  100°,  the  dressing  was  taken 
off  to  inspect  the  stump.     This  was  perfect,  and  the  dressing  was  reapplied.) 


WOUNDS  109 

In  both  cases  the  operation  was  as  follows  : — 
Ax.ESTHETic. — ^Morphia    and    atropine,    chloroform,  followed  bv 
ether. 

1.  The  limb  was  elevated  to  a  right  angle,  and  rubbed  upwards 
to  stimulate  the  vasoconstrictors  and  empty  it  of  venous  blood. 

2.  A  thick,  broad  indiarubber  bandage  was  applied  as  a  tourni- 
quet, one  layer  of  bandage  over  another,  to  the  upper  part  of  the 
thigh. 

3.  The  limb  was  amputated  by  the  circular  method  at  the  junc- 
tion of  the  middle  with  the  lower  third  of  the  thigh. 

4.  The  femoral  artery  and  vein,  and  any  smaller  vessels  which 
could  be  demonstrated  b}-  squeezing  the  limb  above,  were  caught, 
and  ligatured  with  catgut. 

5.  First,  the  periosteum,  then  the  muscles  and  subcutaneous 
fat,  and  finally  the  skin,  were  sutured  in  tiers  with  catgut  over  the  end 
of  the  bone.     The  skin  suture  was  subcuticular,  and  of  catgut. 

6.  The  dressing  was  applied,  and  the  bandage  firmly  fixed. 

7.  The  tourniquet  was  removed,  and  the  patient  sent  to  bed. 

The  Treatment  of  an  Accidental  Wound  requires  variation  of 
the  measures  referred  to,  for,  in  every  instance,  it  is  essential  to  assume 
the  introduction  of  micro-organisms,  and  to  act  with  this  knowledge. 

As  soon  as  haemorrhage  has  been  arrested,  and  the  general  condi- 
tion of  the  patient  has  received  attention,  the  wound  should  be  covered 
with  gauze,  wrung  out  of  1-20  carbolic  lotion;  the  skin  around  the 
wounded  area  should  be  thoroughly  cleansed,  as  previously  described  ; 
and  the  wound  surrounded  by  protective  antiseptic  towels,  as  at  an 
operation. 

The  history  of  the  wound  may  be  of  the  highest  value.  This 
should  be  carefully  enquired  for,  and  considered,  as  a  guide  to  its 
probable  extent  and  importance.  The  surgical  ideal,  however,  is 
to  see,  or  at  least  to  feel,  every  part  of  the  wound  ;  and  it  is  only 
when  the  patient's  interests  are  likely  to  be  endangered  by  the  strict 
observance  of  such  a  useful  rule,  that  excuse  can  be  offered  for 
neglect  of  it.  It  is  unnecessary  to  emphasize  the  fact  by  relating  the 
unexpected  finds  of  foreign  bodies  in  the  wound,  or  the  discovery 
of  wholly  unsuspected  perforation  through  the  skull ;  or  into  the 
peritoneal  cavity;  or  into  a  large  joint;  because,  serious  as  these  are, 
their  importance  is  overshadowed,  in  the  majority  of  instances,  by 
the  probable  introduction  of  infective  organisms.  It  is  often  needful 
to  extend  the  skin  wound  for  exploration — especially  in  wounds  of 
the  scalp  and  of  the  abdominal  wall — to  discover  penetration  ;  and 
by  this  means,  and  the  use  of  retractors,  specula,  and  search-lights, 
the  exploration  of  difficult  wounds  may  usualty  be  made  complete. 


110 


WOUNDS 


The  secret  of  good  surgery  is  to  leave  as  little  as  possible  to 
chance.  Where  the  presence  of  foreign  bodies  is  possible,  the  pre- 
liminary use  of  Roentgen  rays  may  offer  invaluable  aid  (Fig.  86). 
The  signs  of  nerve  or  tendon  injury,  or  such  gross  indications  as 
cerebral  pulsations  in  the  blood  of  a  scalp  wound ;  or  the  escape  of 
omentum,  f?eces,  or  flatus  from  an  abdominal  wound  ;  or  the  pre- 
sence of  other  lesions,  must  not  be  overlooked  before  the  treatment 
of  the  wound  has  been  fully  undertaken. 


Fig.  86. — Foreign  Body  Embedded  in  Tissues  o\-er  Front  of  Elbow  Joint. 


The  first  object  in  such  treatment  is  to  remove  all  foreign  bodies 
and  dirt.  A  stream  of  hot  (105°  F.)  normal  saline  (  3j  of  salt  to  a 
pint  of  water)  is  run  continuously  into  the  wound  during  its  explora- 
tion ;  and  foreign  bodies  are  to  be  removed,  obvious  dirt  wiped 
away,  and  tissues  so  much  damaged  as  to  be  clearh^  beyond  recovery 
excised.  It  is  well  to  remember,  when  dealing  with  wounds  in  con- 
spicuous situations,  that  skin  ingrained  with  gunpowder  or  coal  dust 
never  loses  the  stain  unless  all  particles  of  these  can  be  removed 
from  it,  and  that  the  best  way  of  doing  this,  if  there  is  plenty  of 
skin,  is  to  excise  the  damaged  portion. 


THE   ABDOMINAL   AND   PELVIC   VISCERA       ill 

If  the  wound-cleansing  appears  to  be  satisfactory,  an  attempt 
should  be  made  to  complete  restoration  of  all  the  parts — deep  and 
superficial — to  their  normal  relations,  by  catgut  sutures  for  the  deep, 
and  fishing-gut  for  the  superficial,  parts.  A  small  opening  for  drainage 
should  be  left  in  the  skin  wound,  and  the  dressing  may  consist  of 
sterile  gauze,  wrung  out  of  i-iooo  spirit  corrosive  lotion,  covered  by 
an  abundance  of  cotton-wool  and  retained  by  a  firm  bandage.  If 
there  is  no  pain,  no  rise  in  temperature,  and  no  discharge — as  should  be 
the  case  if  the  cleansing  has  been  successful — the  dressing  may  safely 
be  left  for  ten  days,  and  the  drainage  tube  need  not  be  disturbed 
during  this  time.  If  there  are  either  pain,  elevation  of  temperature, 
or  discharge,  the  wound  should  be  inspected,  and  evidences  of  in- 
flammation expected.  Infection  of  the  wound  requires  the  removal 
of  stitches,  the  opening  up  of  the  entire  wounded  area,  gentle  packing 
of  it  twice  a  day,  from  the  bottom,  with  iodoform-formalin -glycerin 
gauze,  and  the  use  of  Bier's  apparatus,  till  the  evidences  of  sepsis 
have  all  disappeared.  Then  it  may  be  possible  to  draw  granulating 
surfaces  together. 

If  doubt  is  felt  about  the  cleansing  of  the  wound,  it  is  best 
to  leave  it  entirelv  open,  for  drainage,  and  gently  packed  from 
the  bottom  till  all  doubt  is  removed  ;  then  to  make  the  best 
of  bringing  the  parts  together,  when  covered  with  healthy 
granulations. 

For  infected  wounds  of  the  extremities.  Bier's  bandage  is  most 
useful.  It  should  be  kept  on  for  tw^enty-two  hours  of  the  twenty- 
four,  and  taken  off  for  an  hour  night  and  morning.  If  properly 
applied,  the  limb  below  turns  of  a  reddish-blue  colour,  the  bandage 
produces  some  swelling,  relieves  the  pain,  and  increases  the  dis- 
charge. The  wound  can  be  dressed  with  boric  lint  wrung  out  of  hot 
boric  lotion,  covered  wnth  w-aterproof.  and  frequently  changed. 


THE    ABDOMINAL    AND    PELVIC    VISCERA. 

]\Iuch  confusion  and  bewilderment  of  thought  have  been  occa- 
sioned by  a  wrong  habit  of  regarding  certain  portions  of  the  body 
as  allocated  to  one  or  another  division  of  regional  surgery,  with 
implied  special  conditions,  and  apart  from  a  due  consideration  of 
general  principles.  In  regard  to  abdominal  and  pelvic  surgery,  this 
tendency  has  been  most  noticeable. 

Inflammation. — To  anv  one  who  has  considered  the  causes  of 
acute  inflammation  and  its  terminations,  it  would  be  easy  to  under- 
stand the  pathology  of  three  of  the  most  discussed  diseases  of  the 


112      THE   ABDOMINAL   AND   PELVIC   VISCERA 

present  day — appendicitis,  pancreatitis,  and  cholecystitis.  Such  an 
one  would  expect  the  cause  to  be  infection  with  pyogenic  organisms  ; 
and  that  the  condition  would  end  in  either  resolution ;  fibrosis ; 
ulceration  and  abscess  (including  sloughing)  ;  or  gangrene  ;  these  being 
the  four  terminations  of  inflammation. 

With  regard  to  chronic  inflammation — which  here  is  nearly  alwa^^s 
due  to  tubercle — the  same  rule  of  thought  applies,  for  the  difficulties 
in  the  abdomen  are  the  same  as  are  associated  with  tubercle  elsewhere. 
There  is  the  same  tendency  to  infect  lymphatic  glands,  and  for  them 
to  soften  and  break  down,  or  calcify  ;  the  same  tendency  to  slow, 
obstinate  ulceration  ;■  the  same  natural  cure  by  fibrosis  ;  the  same 
mimicry  of  cancerous  and  sarcomatous  growths,  and  ulcers  ;  and  the 
same  need  for  remembering  the  specific  underlying  disease  as  a 
frequent  cause  of  obscure  or  indefinite  tumours  or  fluid  effusions. 


The   Hollow   Viscera. 

All  of  these  possess  the  power  of  contraction,  b}^  virtue  of 
the  unstriated  muscle  in  their  walls.  The  ordinary  contractions 
of  unstriated  muscle  are  not  perceived ;  they  are  painless.  The 
forcible  contractions  of  unstriated  muscle,  on  the  other  hand,  cause 
the  most  severe  pain  that  human  beings  can  experience.  All  the 
colics  are  examples  ;  labour  is  a  physiological  demonstration  of 
this  fact. 

The  most  usual  stimuli  to  forcible  contraction,  are,  the  presence 
of  a  foreign  body,  plus  inflammation  ;  or  rapidly  increased  tension. 
Excess  of  carbonic  acid  in  the  blood  is  also  a  predisposing  cause  of 
active  contraction  in  unstriated  muscle.  During  sleep  the  quantity 
of  carbonic  acid  in  the  blood  is  increased  ;  hence  the  frequency  with 
which  colic  awakens  the  patient  in  the  early  hours  of  the  night,  when 
sleep  is  deepest. 

After  prolonged  and  intense  effort,  exhaustion  of  the  muscular 
walls  follows,  and  relief  from  the  severe  pain  results,  even  though 
its  cause  be  not  removed.  Instances  of  this  in  the  urinary  and 
gall-bladders,  the  intestines,  the  ureter,  the  bile-ducts,  and  the 
pregnant  uterus,  are  not  rare. 

In  all,  after  a  variable  period,  if  not  relieved  by  att,  the  violent 
spasmodic  pains  gradually  cease,  the  exhausted  muscular  walls  no 
longer  contract,  and  only  an  aching  and  tenderness  are  left. 

All  the  hollow  viscera  react  in  a  similar  manner  to  stimuli.  If 
the  obstacle  to  be  overcome  causes  a  partial  obstruction,  their  walls 
thicken  from  hypertrophy,  and  their  cavities  diminish.  Examine 
the  bladder,  when  a  stricture  of  the  urethra  has  been  present  for  some 


THE     HOLLOW    VISCERA 


113 


years  {Fig.  87.)  Its  cavity  is  so  small  that  frequent  urination  is 
the  patient's  chief  complaint,  its  walls  may  be  as  thick  as  those  of  a 
uterus.  In  one  patient  on  whom  I  operated,  the  bladder  cavity 
was  so  small  that  I  could  only  introduce  the  tip  of  my  little  linger 
into  it,  and  its  walls  were  so 
thick  that  on  bimanual  exam- 
ination— a  linger  in  the  rectum 
and  a  hand  pressing  over  the 
pubis — the  bladder  felt  Hke  a 
cricket    ball. 


Fig.  87. — Urinary  Bladder,  with  Stricture 

OF  Urethra. 
Small  cavity.     Thick  walls.     Partial  obstruction. 

(.S)  Stricture. 


Fig.     88. — Gall-bladder,    \\^TH    common    duct 

STONE    not    LARGE   ENOUGH   TO   FILL  DISTENDED 

Common  Duct. 
Partial  obstruction.     Small  cavity.     Thick  walls. 


In  the  gall-bladder  the  same  thing  has  been  observed,  and  described 
as  Courvoisier's  law.  When  the 
bile  circulation  is  partially  ob- 
structed, as  it  is  when  a  gall- 
stone is  in  the  common  duct, 
the  gall-bladder  cavity  gradually 
decreases,  its  walls  thicken,  and 
the  contraction  may  be  so  great 
as  to  cause  difficulty  in  finding 
that  viscus  {Fig.  88). 

In  some  cases  of  pyloric 
stricture  the  cavity  of  the 
stomach  becomes  so  small,  and 
the  walls  of  it  so  thick,  that  the 
whole  organ   comes    to   resemble 

.i-i  J      •     J.      A.-  ,  T^  ■         r>\  Fig.  8n. — Stomach,  with  Strictl-re  of  Pyloru.s. 

a     thickened     mtestme      {Fig.     89).  small  cavity.    Thick  walls.    partial  obstmction. 

8 


114 


THE     HOLLOW     VISCERA 


If  the  obstacle  to  be  overcome  prove  invincible  {total  obstruction), 

the  muscular  walls 
cease  to  contract ;  the 
violent  pains  abate  ; 
paresis  of  the  muscular 
coat  occurs,  and  is  fol- 
lowed by  passive  disten- 
tion of  the  viscus,  and 
perhaps  at  a  later  period 
by  degeneration  of  the 
unstriated  muscle. 

Patients  not  infre- 
quently come  to  the 
Infirmary  with  a  urinary 
bladder  distended  to  the 
umbilicus,  complaining 
only  that  "  they  cannot 
keep  their  water."  The 
painful  period  has  been 
succeeded  by  relief,  and 

Fi,.    90.-URIXARV    BLADDER,   ^^1XH    EXLARGED    PROSTATE.  ^^^       bladdCr        distCntiOU 

I^rge  cavit.v.     Thin  walls.     Complete  obstruction.  by   OVCrfloW    {Fig.    9O.) 


Hydrops  of  the  gall- 
bladder is  not  uncommon, 
and  is  usually  due  to  a  large 
gall-stone  iirmly  impacted  in 
its  neck,  and  distention  of 
the  cavity  by  secretion  from 
its  mucous  lining.  The  his- 
tory, generally,  is  that  after 
a  violent  attack  of  pain,  of 
some  hours'  duration,  relief 
gradually  came,  and  a  ten- 
der "  lump  "  followed  some 
days  later  (the  distended 
gall-bladder). 

If  the  common  bile- 
duct  is  completely  blocked 
by  a  growth  in  it,  or  in  the 
head  of  the  pancreas,  there 
is  painless  distention  of  the 
gall-bladder  {Fig.  91).  To 
the  combination  of  jaundice 


Fiq.  91. — Gai.l-bladder,  with  Enlarged  Head  of 

Pancrea.s  and  Dlstended  CoiLMON  Duct. 

Large  cavity.     Thin  walls.     Complete  obstruction. 


THE     HOLLOW     VISCERA 


115 


with  a  distended  gall-bladder,  high  diagnostic  significance  is  attached  ; 
for  it  is  usually  due  to  complete  obstruction  of  the  common  bile- 
duct  from  malignant  disease. 


ure 


Fi%.  92. — Cecum  and  Colox,  with  Strictl-re 

OF  Sigmoid. 

Small  cavity.     Thick  walls.     Partial  obstniction. 


Vif..  93. — C.T.cuM  AND  Colon,  with  tight 

.Stricture  of  Sigmoid. 

Large  cavity.     Thin  walls.     Complete  obstruction. 


Painless  distention  of  the  caecum  occasionally  follows  a  block  of 
the  sigmoid  flexure  {Figs.  92  and  93)  ;   enormous  painless  distention 


Fiz.  94. — Stomach,  \wt-a  Stricture  of  Pylorus. 
Large  cavity.     Thin  walls.     Obstruction  nearly  complete. 

of  the  stomach,  an  obstructed  pylorus  {Fig.  94)  ;    hydrosalpinx  and 
hj'drops  of  the  vermiform  appendix  may  follow  a  limited  occlusion. 


116 


THE     HOLLOW     VISCERA 


Stone  lmpa£tcd 


If  active   infiammation    is    superadded  to    obstruction,  the  intra- 
visceral  tension  may  become  so  acute  that  the  circulation  is  interfered 

with,  and  partial  or  total  gangrene 
of  the  involved  viscus,  to  be  followed 
by  its  rupture,  will  take  place.  It 
must  be  noted  that  not  every  form 
of  gangrene  is  due  to  this  mechanical 
cause.  As  in  the  body  elsewhere, 
there  are  instances  of  infective  gan- 
grene, due  to  virulent  inflammation 
following  infection  by  organisms  ; 
but  here,  as  elsewhere,  these  are 
rare,  and  are  marked  by  their  rapid 
spread,  and  their  absence  of  relation 
to  the  blood-supply.  The  conditions 
which  we  are  considering  are  due 
to  mechanical  interference,  and  the 
gangrene  commences  at  a  spot  far- 
thest from  the  source  of  the  vascular 
supply  ;  for  example,  in  the  gall- 
bladder it  is  first  observed  at  the  fundus  {Fig.  95)  ;   in  the  urinary 


Common  Duct 


Fig.  95. — DiAGRAJi  OF  Gall-bladder  to 
Illustrate  Tension  Gangrene. 


Fig.  (j6. — Tension  Gangrene  of  Bladder, 
(A)  Prostatic  abscess.  (G)  Gangrene,  (i)  Superior 
vesical  arteries.  (2)  Mid-vesical  arteries.  (3) 
Inferior  vesical  arteries.  The  diagram  is  from 
a  specimen  removed  from  :\  yoimg  man  who 
had  retention  of  three  days'  duration  from 
acute  gonorrhoea!  prostatitis  and  excessive 
whisky  drinking. 


Fig.   97.- 


-Diagratm  of  Appendix  to  Illustrate 
Tension  Gangrene. 


THE     HOLLOW     VISCERA 


117 


bladder  at  the  superior  portion  of  the  posterior  wall   {Fig.  96)  ;    in 

the  vermiform  appendix 

{Fig.  97)  and  the  small 

intestine    {Fig.    98),    at 

a    point    opposite     the 

mesentery;      in     the 

c?ecum,  in  the  neigh- 
bourhood of  its  anter- 
ior   longitudinal     band 

{Fig.  99).  In  each  in- 
stance  it   appears  as   a 

rounded  or  oval  patch, 

which  steadily  spreads. 
All  muscular  tubes, 

such    as    the    intestine, 

urethra,   bile-duct,   and 

ureter,  act  in  a  similar 

way    when     a     foreign 

body  attempts    to  pass 

through  them.  .4  rela- 
tively   small    body    such 

as  a    stone   of    moderate 

size   may  set  up  violent 

spasmodic     contractions, 

and  he  so  tightly  gripped  as  to  cause,  temporarily,  complete  obstruction. 

At  a  later  stage,  the  icalls  of 
the  muscular  tube  recede  from 
the  foreign  body,  and  active 
dilatation  follows. 

When  a  large  gall-stone 
has  found  its  way  by  ulcera- 
tion through  the  gall-bladder 
into  the  small  intestine,  it 
is  likely  to  cause  intestinal 
obstruction.  The  attack  is 
characterized  by  starting  with 
violence ;  ending  in  relief ; 
but  followed  by  recurrence, 
probably  on  several  occasions, 
before  the  stone  escapes,  or 
is  removed  by  operation. 
The  explanation  is,  that  the 
stone,  gripped  at  some  stage 

of  its  progress,  causes  intestinal  obstruction  ;    relaxation  round  the 


Fig.  98. — Acute  Ixtestinai.  Obstruction  of  Two  Days' 

Duration". 

(A)  Gangrenous  patch.      (B)  Small   intestine  distended.      {€) 


Constricting   band.      (D)   Collapsed  intestine, 
teric  vessels. 


(F)  Jlesen- 


99. — Diagram  to  Illustrate  Tension 
Gangrene  in  the  Cecum. 


118 


THE     HOLLOW     VISCERA 


stone  relieves  this,  and  the  stone  passes  on  until  either  further  arrest 
with  recurrence  of  s^^mptoms,  or  its  escape  from  the  intestine,  occurs. 
A  small  stone  arrested  in  the  urethra  may  cause  temporary  retention 

of  urine ;  in  the  ureter,  intermittent 
hydronephrosis ;  and  in  the  common 
bile-duct,  intermittent  jaundice  {Fig. 
lOo) ;  because  the  small  stone,  and 
spasmodic  contraction  of  the  muscular 
tubes,  cause  a  temporary  block.  So 
soon  as  the  spasm  relaxes,  the  con- 
dition in  each  is  relieved.  A  large 
stone  is  unlikely  to  cause  complete 
blocking  of  any  of  these  muscular 
tubes,  on  account  of  their  active 
dilatation  round  the  foreign  body.  In 
the  presence  of  a  ureter  stone,  the  ureter  may  reach  the  size 
of  the  small  intestine  ;  the  enormously  dilated  common  bile-duct, 
with  a  stone  in  it,  has  frequently  been  mistaken  for  the  duodenum 
{Fig.  102). 


Fig.  100. — Size  of  Gall-stoxe  which 

CAUSED     TAUXDICE    .\XD    DEATH    BY 
OCCLrDIXG  THE  COMJIOX  BiLE-DUCT. 

The  s;all-bladder  and  common  duct  had 
been  cleared  (?)  by  operation  two 
weeks  previously,  and  this  stone 
was  onl}-  found  post  mortem.  The 
patient  whilst  convalescent  was 
seized  with  a  severe  attack  of  biliary 
colic.  Next  day  was  jaundiced,  and 
died  suddenly,  syncopal,  three  days 
later. 


-Urinary  Bladder  Retention  from  Stone 
IN  Urethra. 

iA)  Bladder.  (B)  Prostate.  (C)  .Symphysis  pubis.  (D)  Tri- 
angular ligament.  IE)  Stone  impacted  in  urethra.  When 
of  this  size  it  may  cause  complete  obstruction. 


Fig.  102. — Not  Uncommon  Size  of  Cojimon 

BlI.E-DUCT  WITH    GALI.-STOXE   IN   IT. 

(A)  Bile-duct.  (B)  Gall-stone.  (C)  Pan- 
creatic duct.  (D)  Ampulla.  (£1  Duo- 
denum. (Drawing  two-thirds  natural 
size.) 


THE     HOLLOW     VISCERA 


119 


Fj?.   103. — Meckel's  Diverticuluji. 

[A)  Small   intestine.       (B)   Diverticvilum— wall  fonned 
by  all   the  coats  of  the  intestine.     Diverticula  are 

con"enilal. 


Diverticula  and  Sacculi. — Confusion  has  arisen  between  these 
conditions,  etiologically  distinct,  because  of  resemblances  in  their 
pathology. 

The  diverticula  are  of 
congenital  origin.  All  coats 
of  the  intestine  enter  into 
their  composition.  All  have 
a  special  vascular  supply  of 
their  own.  They  are  seldom, 
if  ever,  multiple,  and  are 
found  at  any  age.  The 
vermiform  appendix  is  re- 
presentative of  this  type  in 
the  normal  subject.  Meckel's 
diverticulum,  due  to  arrested 
involution  of  the  omphalo- 
mesenteric duct,  is  the  most 
common  abnormal  diverti- 
culum   {Fig.    103).       Others 

are  associated  with  small  supernumerary    pancreatic   outgrowths  at 

any  part  of  the  gastro- 
intestinal tract,  and  trac- 
tion diverticula  have  also 
been  described.  As  these 
latter  are  due  to  the  me- 
chanical drag  of  a  small 
adhesion,  they  should  be 
classified  by  themselves. 

Sacculi  differ  from  di- 
verticula in  that  they  are 
never  of  congenital  origin, 
and  have  consequently  not 
been  found  in  youth  :  are 
associated  with  obstruction 
of  the  outlet,  and  weakness 
of  the  wall,  of  the  affected 
viscus  ;  are  multiple  ;  are 
thin-walled,  because  they 
are  mostly  hernias  of  the 
mucous  coat  through  the 
muscular  coat  ;  are 
rounded  in  shape  ;  do  not 
attain  to  very  large  size  ;  and  are  practically  limited  to  advanced 
life.    In  the  urinary  bladder  {Fig.  104),  all  parts  of  the  gastro -intestinal 


Fig.  104. — Sacculi  of  Bladder. 
(B)  Bladder.     (P)  Prostate.     (S)  Sacculi. 


120 


THE     HOLLOW    VISCERA 


fig.   105. — Multiple  Sacculi. 

{A)  Lumen  of  intestine.  (B)  AValls  of  sacculi  formed 
mainly  bv  mucous  membrane  (and  peritoneum).  Sacculi 
are  acquired. 


tract  {Fig.  105),  the  gall-bladder  [Fig.  106),  the  vermiform  appendix 
{Fig.  107),  and  Fallopian  tubes,  similar  swellings  have  been  described; 

indeed,  it  is  safe  to  say 
that  they  will  be  found,  if 
sought  for,  in  any  of  the 
hollow  muscular  -  coated 
viscera.  It  seems  probable 
that  some  of  the  so-called 
diverticula  of  the  oesophagus 
are  true  diverticula ;  but 
some  of  them  are  sacculi ; 
and  the  distinction  should 
be  made  here  as  elsewhere. 
Sacculi  in  the  urinary  bladder  and  in  the  colon — especially  in 
the  sigmoid  flexure,  where 
they  are  most  common — 
may  be  of  the  greatest 
surgical  importance,  for 
they  are  subject  to  the 
same  pathological  changes 
that  occur  in  the  vermi- 
form appendix  and  other 
diverticula.  All  of  them 
may  harbour  concretions, 
and  all  of  them  are  liable 

to   attacks   of   inflammation   with  the  ordinary  terminations.     It  is 

therefore  possible  to  find 
a  Meckel's  diverticulum 
with  a  faecal  ball,  or  a 
calculus,  in  it.  It  is  also 
possible  to  find  it  either 
fibrosed  and  adherent,  or 
ulcerated,  with  perfora- 
tions in  it  and  an  abscess 
round,  or  totally  gangren- 
ous, as  in  appendicitis. 
Similar  changes  occur  in 
the  bladder  and  colon 
altered  by  sacculi,  so  that 
it  is  possible  to  have  on 
the  left  side,  as  a  conse- 
quence of  sacculitis  of  the 
sigmoid,    gangrenous   per- 

Fi^.  107. — .Sacculi  OF  Appendix.  .  .  .    , 

(A)  Cacum.     (B,  Appendix.     (C)  Sacculi.  foratlOU    With     pcntomtlS  ; 


Fis.   106. — Sacculi  of  Gall-bladder. 
{A)  Edge  of  liver.      (B)  Gall-bladder.     (C)  Saccule. 


THE     HOLLOW     VISCERA  121 

ulceration  and  perforation  with  left  iliac  abscess  ;  or,  inflammatory 
thickening  and  fibrosis,  so  closely  resembling  a  malignant  growth  of 
the  affected  bowel,  that  after  examination  by  macroscopic  section 
alone,  a  diagnosis  may  be  impossible. 

Calculi. — Though  calculi  may  be  found  in  various  parts  of  the 
body,  and  in  different  organs  (blood-vessels,  brain,  salivary  glands), 
their  favourite  site  is  in  these  abdominal  and  pelvic  viscera,  which  are 
hollow,  and  are  lined  by  mucous  membrane.  Many  of  them  are 
associated  with  infection  of  the  mucous  lining  by  micro-organisms, 
but  all  of  them  require  other  unknown  conditions  for  their  develop- 
ment. 

The  ordinary  calculus — not  the  variet}^  associated  with  active 
infection — may  be  regarded  as  a  foreign  body,  for  it  behaves  as  such. 
Like  aseptic  foreign  bodies,  when  undisturbed  and  quietly  resting, 
calculi  cause  no  serious  trouble,  and  few,  if  any,  symptoms.  Like 
foreign  bodies,  they  weaken  the  normal  resistance  of  the  surrounding 
tissues,  and  predispose  to  infection.  As  in  the  case  of  foreign 
bodies,  when  once  infection  has  occurred,  it  is  difficult  to  get  rid 
of  until  the  calculus  has  been  extruded  or  removed. 

Bladder  calculi  have  grown  to  a  large  size  without  causing 
urgent  symptoms  or  serious  trouble.  The  symptoms  described  as 
characteristic  of  vesical  calculus  are  those  of  calculus  and  cystitis. 
Violent  contractions  of  the  muscular  bladder-wall  then  follow^  its 
increased  sensibility  and  the  stimulation  of  its  mucous  membrane. 

Renal  calculi  may  be  present  for  years  without  causing  trouble. 
The  symptoms  described  as  characteristic  of  renal  calculus  are  either 
due  to  increased  renal  tension,  or  to  superadded  inflammation.  The 
most  typical  attacks  of  renal  colic  are  due  to  increased  renal  tension 
from  acute  hydronephrosis.  This  may  be  due  to  a  movable  calculus 
falling  into  and  blocking  the  kidney  pelvis,  or  to  a  stone  passing  down 
the  ureter,  and  causing  blockage  through  spasm.  The  attack  may 
be  imitated  by  distending  the  kidney  pelvis  by  fluid  injection  through 
a  ureter  catheter  ;  or  by  any  other  condition  capable  of  causing  acute 
obstruction  to  the  escape  of  urine  from  the  kidney  (hydatid  cysts, 
tuberculous  debris,  blood-clots,  ureter  kinks,  etc.). 

Another  ordinary  cause  of  the  s3aTiptoms  described  as  typical 
of  renal  calculus,  is  superadded  inflammation  of  the  mucous  membrane 
of  the  kidney  pelvis  (pyelitis)  and  ureter.  A  stone,  which  does  not 
cause  obstruction,  may  lie  in  the  kidney  pelvis  for  years,  without 
causing  trouble  {Fig.  io8) ;  but  as  soon  as  the  sensibilitv  of  the 
mucous  membrane  of  the  pelvis  and  ureter  are  increased  by  inflam- 
mation, violent  contractions  of  their  muscular  coats  are  set  up  in 
endeavours  made  to  extrude  the  stone. 


122 


THE     HOLLOW     VISCERA 


Many  renal  calculi  have  been  passed  without  any  knowledge  of 
their  presence,  or  descent,  until  they  stuck  in  the  urethra,  or  attracted 
attention  by  the  noise  of  their  escape.  A  very  usual  evidence  of 
kidne}^  calculus,  and  the  first  sign  of  trouble  from  it,  is  a  renal  abscess. 
On  opening  this,  a  stone,  or  stones,  which  have  taken  years  to  form, 
are  found,  with  a  past  history  that  conveys  no  serious  suggestion. 


Fig.  io8.— Renal  Calculi. 


Biliary  calculi  may  be  present  in  the  gall-bladder,  or  even  in 
the  bile  ducts,  for  long  periods  of  time,  and  cause  no  serious  trouble. 
The  "  attacks  of  biliary  colic,"  said  to  be  characteristic  of  gall-stones, 
are  due  to  violent  contractions  of  the  muscular  coats  of  the  gall- 
bladder or  bile-ducts.  These  are  produced,  either  b}^  increased 
tension,  or  by  increased  sensibility  from  inflammation  of  the  mucous 


INVERSIONS     AND     TORSIONS 


123 


lining.  Typical  biliary  colic  will  follow  distention  of  the  gall-bladder 
with  fluid  from  a  syringe ;  it  will  also  follow  the  discharge  of  blood-clot 
from  an  inflamed  gall-bladder  which  has  been  emptied  of  stones  and 
returned  closed  into  the  abdomen. 

The  largest  biliary  calculi — and  in  this  they  resemble  bladder 
and  renal  stones — are  those  in  which  the  "  characteristic  symptoms  " 
are  most  likely  to  be  absent.  Biliary  calculi,  the  size  of  hens'  eggs, 
have  been  slowly  extruded  by  ulceration  into  the  intestine,  and  the 
first  evidence  of  illness  has  been  an  attack  of  acute  intestinal  obstruc- 
tion. The  gall-stone,  whilst  in  the  gall-bladder,  caused  no  trouble. 
Like  all  the  other  calculi,  gall-stones  can  make  a  painless  escape. 

Prognosis. — In  all  of  them  the  symptoms  of  their  presence  are 
the  result  of  calculus,  plus  complications  likely  to  produce  progressive 
mischief,  and  unlikely  to  terminate  in  a  satisfactory  natural  cure. 

Treatment. — The  treatment  in  all  of  them  is  to  remove  the 
stones  before  further  complications  and  more  damage  have  been 
inflicted. 

Inversions   and   Torsions. 

Inversions.  —  The  tendency  to  turn  inside-out  seems  common 
to  all  of  the  hollow  viscera,  for  it  has  already  been  recorded  of  so 
many  of  them.     In  the  intestines  it  is  described  as  intussusception. 


Fig.  109. — Intussusception  due  to  Polypus. 

(-1)  Proximal  intestine.     (B)  Entering  layer.     (C)  Returning  layer.     (D)   Ensheathing  layer. 

{£)  Mesentery. 


inversion  of  the  appendix,  and  prolapse  of  the  rectum  ;  in  the  uterus 
as  inversion  ;  the  inverted  ureter  has  found  its  way  out  of  the  female 
urethra  ;   and  the  vagina  and  the  urethra  may  both  be  prolapsed. 

The  cause  in  the  majority  of  cases  is  unknown,  but  it  seems 
probable  that  the  prolapse  is  of  an  abnormally  active  portion  above, 
through  an  abnormally  passive  part  below. 

Attempts    to    extrude    a   tumour    in    the    intestine    {Fig.    109), 


124 


INVERSIONS     AND     TORSIONS 


and    in   the   uterus  {Fig.    no),    have  given  rise  to  the  condition — 
Polypi  in  the  intestines  ;    Fibroids  in  the  uterus. 

In  all  of  them  it  ma}^  be  acute  and  serious  in  results,  or  chronic 
and  causing  no  grave  symptoms  ;  and  in  all,  this  is  determined  by 
the  condition  of  the  vascular  supply  of  the  prolapsed  portion.  If  the 
part  inverted  is  so  constricted  by  the  area  through  which  it  passes, 
as    to    interfere    with    the    return    of    its  venous   blood,  the  serious 


Fig.  no. — Chronic  Inversion  of  the  Uterus  with  Fibroid  Tu.aiour. 

{A)  Vagina.     (B)  Fibroid  polj-pus.     (C)  Cervix.     (D)  Inverted  fundus  uteri.     (£)  Cup-shaped  hollow. 

(F)  Fallopian  tube. 


symptoms  and  signs  of  strangulation — pain  and  collapse,  thrombosis, 
ulceration,  sloughing,  gangrene — result.  If,  on  the  other  hand,  there 
is  no  obstructed  circulation,  the  symptoms  will  only  be  those  of 
a  mechanical  disturbance,  and  the  course  chronic. 


Torsions. — Twists  are  common  to  nearly  all  of  the  abdominal 
viscera.  The  intestine  {Fig.  in),  (volvulus),  stomach,  gall-bladder, 
appendix,  kidney,  spleen,  omentum,  uterus  (pregnant  and  fibroid) 
{Fig.     112),     distended    Fallopian   tubes    (hydrosalpinx,    pyosalpinx, 


INVERSIONS     AND     TORSIONS 


125 


F/?.  III. — Volvulus  of  Sigmoid  Flexure  of  Colon. 


":"/  uterus -m:'K' 


Fig.   112. — Volvulus  of  Subperitoneal  Fibroid. 


126 


INVERSIONS     AND     TORSIONS 


ectopic    gestation),    ovaries,    and    testes,    are    each    liable    to     such 
accident. 

The  sudden  attack ;  the  mystery  of  its  onset ;  the  associated 
dangers  and  pain;  and  the  amenability  of  the  condition  to  surgical 
treatment,  have  made  this  subject  one  of  special  interest. 

Whatever  organ  the  twist  involves,  and  whether  viewed  in 
reference  to  etiology,  pathology,  symptoms,  diagnosis,  prognosis,  or 
treatment,  all  cases  have  many  points  in  common. 

In  order  to  twist,  the  organ  must  have  a  pedicle,  congenital  or 
acquired  ;  and  the  longer  the  better.     It  must  have  space  to  turn  in, 

and   a    shape   which  will  allow   of 
rotation. 

Ovarian  Tumours  with  Tor- 
sion of  the  Pedicle, — No  other 
movable  body  answers  to  these 
requirements  as  does  an  ovarian 
tumour  ;  and  accordingly,  the 
majority  of  torsions  are  associated 
with  ovarian  tumours  {Fig  T13). 

The  presence  of  a  second 
ovarian  tumour,  or  of  a  pregnant 
uterus,  predisposes  to  twisting ;  so 
does  the  fact  that  the  tumour  is  a 
dermoid.  The  probable  explana- 
tion is,  that  one  swelling  helps  to 
roll  the  other  over,  and  that  der- 
moid tumours,  being  lighter  than 
ordinary  ovarian  tumours,  are  more 
easily  rotated. 

Volvulus    of    the    Intestine. — 
Next  to  ovarian  tumours  the  intes- 
tine is  most  liable  to   twists ;    but  volvulus  of  the  intestine,  though 
not  extremely  rare,  has,  judging  by  current  diagnosis,  its  frequency 
exaggerated. 

Normal  intestines  do  not  meet  two  of  the  requirements  necessary 
for  the  production  of  a  volvulus — a  pedicle,  and  a  shape  which  will 
allow  of  rotation — but  two  recognized  conditions  may  permit  of  this. 
The  first  is  a  congenital  or  acquired  defect  in  the  intestinal  attach- 
ments allowing  of  wide  mobihty ;  and  the  second,  one  which  produces 
an  artificial  pedicle.  In  the  first  type,  the  volvulus  should  be  regarded 
as  primary  ;    in  the  other  as  secondary. 

Of  primary  volvulus  there  are  three  w^dl-known  varieties.     Two 
of  them,  the  most  common,  involve  the  caecum,  and  are  described  as 
I.  Complete  volvulus. 


^T^ikmm-j^ 


Fig.   113. — Volvulus  of  Ovarian  Cyst. 

The  Fallopian  tube  is  represented  in  the  dia- 
gram as  free.     It  is  usually  involved. 


INVERSIONS     AND     TORSIONS 


127 


2.   Partial  volvulus. 

In  the  complete  variet}-  {Fig.  114),*  the  torsion  occurs  round  the 
superior  mesenteric  artery  as  an  axis;  in  the  partial  form,  the  ile(j- 
coHc  artery  forms  the  axis  of  rotation.  In  both,  the  caecum  by  its 
rounded  shape  predisposes  to  volvulus,  and  in  both  a  congenital 
absence  of  the  normal  fixation-bands  of  the  cacuni  and  colon, 
with  arrested  development  and  elongation  of  the  mesentery,  allow 
of   that   pedicle-formation  and   free   movement   which  are   essential. 


Fig.  114. — Complete  Volvulus. 


115. VOLVULU 


Hernial  Sac. 


The  volvulus  may  involve  the  intestine  in 
the  abdomen  and  not  that  in  the  hernial 
sac :  but  in  either  case  the  pedicle  is 
formed  by  the  neck  of  the  sac. 


In  the  first,  the  distended  caecum  is  found  near  the  spleen  ;  in 
the  second,  usually  in  the  pelvis. 

3.  The  third  variety  concerns  the  sigmoid  loop,  and  is  always 
accompanied  by  distended  bowel  and  a  marked  elongation  of  the 
mesentery,  either  congenital  or  acquired. 

Secondary  volvulus  is  the  more  common  form,  and  deserves  wider 
recognition  than  it  has  yet  received,  because  it  is  often  a  dangerous 
addition  to  an  already  serious  lesion.  The  necessary  pedicle  may  be 
produced  by  the  constriction  of  the  neck  of  a  hernial  sac  {Fig.  115) ; 


*  From  Medical  Annual,   190S. 


128 


INVERSIONS     AND     TORSIONS 


by  the  pressure   of  a  band  on  an  intestinal  loop  {Fig.  ii6) ;  or  by 
moderate  torsion  on  an  intestinal  loop  already  fixed  by  an  adhesion 


Fig.  1 1 6. — Volvulus  of  Intestine. 
Under  a  band-adhesion  stretching  from  the  appendix. 


or  by  a  hernia  {Figs.  115  and  117) ;    so  that  the  acute  symptoms 
associated  with  either  a  hernia,  a  band,  or  intestinal  adhesions,  may 


Fig.   117. — Volvulus  of  .Small  Intestine. 
Jleckel's  diverticulum  and  band. 


aU  be  due  to   a  secondary  volvi.lus,  the  hernia,  band,  or  intestinal 
adhesi(jn  acting  only  as  the  predisposing  cause. 


INVERSIONS     AND     TORSIONS  129 

The  Causes  of  Torsion  have  been  largely  discussed,  but  then' 
is  little  real  knowledge  of  them.  Chronic  constipation  ;  congenital 
or  acc^uired  defects  in  attachment  :  and,  in  the  case  of  ovarian 
cysts,  alternate  distention  and  collapse  of  the  sigmoid  flexure 
and  urinary  bladder,  movements  of  the  abdominal  wall,  and 
peristaltic  movements  of  the  intestines,  have  been  specially  men- 
tioned. A  second  tumour,  ovarian  or  uterine,  is  an  aid,  so  is  the 
enlargement  (space  to  turn  in)  resulting  from  recent  pregnancy. 
It  is  possible  that  in  some  cases  the  omentum,  recognizing  the 
tumour  as  an  intruder,   tries  to  hustle  it.  and  thus  starts  the  twist. 

In  the  great  majoritv  of  cases  the  twist  is  from  left  to  right. 
The  reason  for  this  has  been  widely  disputed  ;  but  it  should  be 
remembered  that  a  left  to  right  twist  is  an  inherent  ph^^siological 
trait,  which  reveals  itself,  amongst  other  instances,  in  the  heart's 
beat,  in  the  development  of  the  gastro-intestinal  tract,  and  in  the 
contractions  of  the  uterus  during  labour. 

The  only  exception  to  this,  and  it  is  apparent  onl}',  is  in  the 
complete  volvulus.  In  the  course  of  development  the  caecum  moves 
from  the  middle  line  to  the  right,  that  is,  from  left  to  right.  In 
the  rotation  due  to  complete  volvulus,  the  csecum  is  generally  found 
lying  on  the  left  side,  near  the  spleen,  and  has  passed  over  from 
right  to  left  ;  but  this  is  obviousl}"  the  result  of  the  same  move- 
ment which  started  from  left  to  right. 

The  pathological  changes  that  occur  in  connection  with  twists 
are  in  all  cases  similar,  and  are  due  to  interference  with  the  local 
circulation.  If  recognized  early,  the  twist  can  be  undone.  Later 
changes,  due  to  inflammation  and  matting  of  the  surrounding  tissues, 
may  obscure  the  cause  of  the  condition. 

The  first  change  is  an  engorgement  of  the  veins  of  the  organ 
twisted ;  with  an  effusion  of  blood-stained  serum  into  the  peritoneal 
cavity,  or  into  the  tunica  vaginalis  if  the  case  is  testicular.*  Then 
follow  extravasation  of  blood  into  the  affected  organ,  total  arrest  of 
the  circulation,  and  gangrene.  Afterwards,  the  dead  tissue  acts  as 
a  foreign  body,  and  peritonitis  may  ensue.  If  so,  organisms  from 
the  surrounding  intestines  penetrate  the  dead  or  dying  tissues,  and 
an  abdominal  abscess  results.  Or,  in  the  case  of  small  ovarian  cysts, 
and  those  damaged  gradually  by  a  series  of  twists,  a  new  circulation 
can  be  established  through  new  vessels  formed  in  omental  adhesions, 
and,  following  on  such  a  history,  an  ovarian  tumour  may  then  be 
found  growing  in,  and  from,  the  omentum.  More  rarely  still,  entire 
absorption  of  the  gangrenous  mass  mav  take  place. 


*  So   far   as    I   know,    torsion  of  thf    testicle    only    occurs   when   an    arrest    of 
development  is  present. 


130  INVERSIONS     AND     TORSIONS 

Symptoms. 

In  all  cases,  pain  is  an  urgent  and  striking  symptom ;  and  severe 
abdominal  pain  deserves  more  than  a  passing  notice,  for  it  may  be  of 
considerable  use  in  diagnosis. 

Abdominal  Pain. — All  of  the  internal  viscera  are  insensitive  to 
ordinary  painful  stimuli.  The  stomach,  intestine,  kidney,  liver, 
testis,  uterus,  and  ovaries,  can  be  cut,  crushed,  sewed,  or  burned 
without  producing  pain,  in  the  conscious  patient  ;  but  the  parietal 
peritoneum  is  exquisitely  sensitive  to  all  such  stimuli  ;  the  mesentery 
to  dragging  ;  and  the  viscera  to  internal  tension.  Another  cause  of 
severe  abdominal  pain  is  the  forcible  contraction,  from  any  cause, 
of  unstriated  muscle. 

The  following  four  causes  all  require  consideration  in  abdominal 
diagnosis,   viz.  : — 

1.  Irritation  of  the  parietal  peritoneum. 

2.  Dragging  of  the  mesentery. 

3.  Intravisceral  tension. 

4.  Forcible  contraction  of  unstriated  muscle. 

Irritation  of  the  parietal  peritoneum  from  disease  is  usually  the 
result  of  extravasation  into  the  peritoneal  cavity.  Immediately  on 
the  extravasation  of  the  contents  of  the  stomach — through  a  gastric 
ulcer,  for  example — the  patient  complains  of  intense  pain,  diffuse, 
burning,  and  "  deadly." 

Immediately  the  mesentery  of  a  portion  of  gut,  or  the  pedicle 
of  an  ovarian  tumour,  is  tightly  twisted,  the  patient  feels  "  agonizing  " 
pain,  and  becomes  sick  and  collapsed. 

On  injection  of  the  bladder,  kidney,  pelvis  or  intestine  with 
water,  so  soon  as  distention  of  the  viscus  is  produced,  pain 
develops. 

All  of  the  spasmodic  pains,  "  colics,"  are  due  to  forcible  contrac- 
tion of  the  unstriated  muscular  coats  of  the  hollow  viscera. 

In  all  acute  cases  of  torsion,  the  attack  commences  suddenly, 
with  severe  pain,  increasing  steadily  in  intensity,  and  accompanied 
by  vomiting,  by  the  symptoms  of  collapse  (signs  of  strangulation), 
by  suggestive  tenderness  on  pressure  over  the  involved  organ,  and 
increase  in  size  of  a  tumour  previously  recognized. 

In  all  cases,  the  attack  may  steadily  progress  to  a  fatal  issue,  and 
in  well-pronounced  instances  this  is  the  rule.  The  majority,  however, 
give  a  history  of  one  or  many  previous  attacks,  which  have  either 
been  recovered  from  very  rapidly,  or  else  somewhat  slowly.  In  the 
former,  the  twist  had  become  undone  ;  in  the  latter,  the  circulation 
had  been  successful  in  the  struggle  to  relieve  itself  ;  but  a  permanent 
twist  remained. 


IDIOPATHIC     DILATATION  131 

Testicle,  bowel,  omental,  and  ovarian  cases,  in  which  several 
twists  had  occurred,  have  come  under  our  notice  ;  in  these,  the  last 
attack  had  been  preceded  by  many  of  a  similar  character.  It  was 
clear  that,  though  several  old-standing  twists  were  present,  the  last 
was  the  cause  of  serious  mischief.  No  dangerous  result  may  follow 
even  five  or  six  twists,  the  result  depends  on  the  effect  on  the  local 
circulation.  Half  a  twist,  with  a  short  broad  pedicle,  may  do  more 
damage  to  the  circulation,  and  be  more  serious  in  its  results,  than 
half  a  dozen  when  the  pedicle  is  long  and  narrow. 

The  treatment  of  all  internal  twists  is  the  same,  namely,  by 
operation  as  earl}'  as  possible. 

Strangulation. 

The  clinical  and  pathological  effects  of  strangulation  in  hernia 
have  been  recognized  and  taught  for  many  years.  The  most  serious 
results  from  inversions  and  torsions  are  due  to  the  same  cause,  that 
is,  interference  with  the  circulation  from  strangulation  of  the  blood- 
vessels. 

Idiopathic    Dilatation. 

The  oesophagus,  the  stomach  and  small  intestine,  the  colon  and 
rectum,  the  urinary  bladder,  the  uterus,  the  gall-bladder  and 
common  bile-duct,  and  the  ureters,  have  all  been  found  enor- 
mously dilated,  and  the  most  careful  search  has  failed  to  reveal 
any  sufficient  cause. 

The  condition  may  be  acute  or  chronic. 

In  chronic  cases  the  muscular  coat  of  the  involved  viscus  may 
be  enormously  hypertrophied. 

CEsophagus. — In  the  oesophagus,  the  chronic  variety  is  of  greatest 
interest  and  importance.  It  is  described  as  cardiospasm.  One 
patient  of  mine  could  retain  more  than  one  pint  of  food  in  his 
oesophagus  for  several  hours  {Fig.  ii8). 

Stomach. — In  the  stomach,  the  acute  variety  is  the  most  im- 
portant. In  the  course  of  typhoid  fever ;  after  labour  ;  after  the 
application  of  Sayre's  jacket  for  Pott's  disease ;  but  above  all, 
after  abdominal  operations,  the  stomach  may  dilate  to  such  an 
extent  as  to  appear,  on  post-mortem  examination,  to  fill  the 
abdominal  cavity  {Fig.  119);  and  the  patient  soon  dies  unless  the 
condition  can  be  reheved.  On  passing  a  stomach-tube,  a  quantity 
— often  several  pints — of  foul  greenish  stomach  contents  escapes, 
and  the  relief  is  immediate.  This  condition  is  so  often  met  with 
after  abdominal  operations,  that  suspicion  of  it  should  be  the 
first    entertained    for  a   patient  not  doing  well.      If  extreme  thirst, 


132 


IDIOPATHIC     DILATATION 


sickness,  and  epigastric  distention  are  present,  the  stomach  should 
be  washed  out  without  delay  ;  and  if  the  diagnosis  is  confirmed  by 
this,  the  washing  must  be  repeated  three  or  four  times  a  day  till 
all  danger  has  passed. 

Small  Intestine. — In  the  small  intestine,  it  is  chiefly  of  import- 
ance when  of  the  acute  variety,  and  is  known  as  paralytic  ileus.  This 
has  occurred  in  Bright's  disease,  diabetes ;  and  after  labour  and  other 


Fig.   1 1 8. — Idiopathic  Dilatation  of  the  CEsophagus. 

Drawn  from  a  skiagram  of  a  case  of  cardiospasm.     The  oesophagus,  distended  with  bismuth  porridge, 
is  seen  lying  in  front  of  the  spine. 


injuries  ;  but  is  chiefly  of  interest  as  following  abdominal  operations. 
The  great  majority  described  as  such,  and  following  these  opera- 
tions, result  from  septic  peritonitis,  and  have  no  connection  with 
true  paralytic  ileus,  which  is  very  rare.  The  symptoms,  unlike 
those  due  to  peritonitis,  do  not  usually  commence  till  after  the  third 
day,  and  the  first  to  appear  is  painless  distention.  Pain  is  not  a 
feature  till  forcible  efforts  arc  made  to  obtain  an  action  of  the  bowels, 
and  this  may  cause  pain,  vomiting,  and  increase  of  distention,  but 


IDIOPATHIC     DILATATION 


133 


Fig.   1 19. — Acute  Dilatation  of  Stomach. 
Diagram  of  post-mortem  appearance. 


In  this  patient  the  duodenum  was  dilated  also.  This  condition  has  been 
described  as  gastro-mesenteric  ileus,  and  attributed  to  mechanical  obstruction 
by  traction  of  the  mesentery,  containing  the  superior  mesenteric  artery. 
Descent  of  the  small  intestine  into  the  pelvis  converts  the  mesentery  into  a 
band,  and  blocks  the  duodenal  termination.  That  this  is  not  a  correct  view- 
is  proved  by  the  fact  that  the  dilatation  may  affect  the  stomach  only,  may 
stop  at  any  part  of  the  duodenum,  or  even  extend  for  a  yard  or  more  down 
the  jejunum. 


134 


IDIOPATHIC     DILATATION 


not  the  desired  relief.  In  spite  of  all  remedies,  even  enterostomy, 
the  bowels  will  not  act  ;  and  in  from  seven  to  fourteen  days  the 
patient  dies,  chieflv  as  the  result  of  intestinal  distention  and  heart 
failure. 

Colon. — In  the  colon,  the  chronic  variety  (Hirschsprung's  disease) 
is  of  the  greatest  importance  {Fig.  120). 

The  sigmoid  flexure  is  its  favourite  site ;  but  all  parts  of  the  colon 
may  be  affected  by  it.  The  sigmoid  colon,  enormously  thickened 
and  dilated,  may  be  loaded  with  pounds  of  faecal  matter,  and  suffi- 
cicntlv   distended   to   occupy  the  greater  part   of  a   much   enlarged 


F/j.  120. — Idiopathic  Dilatation  of  the  Colox. 

Case  of  a  child,  xt.  3.     Symptoms  of  chronic  constipation  since  birth.     Note  the  distended  coils  of 

intestine,  and  emaciatioru 


abdomen.  The  condition  commences  in  childhood  ;  and  constipation 
may  reach  such  extremes  that  it  is  necessary  to  empty  the  lower 
bowel  by  manipulation  from  time  to  time.  An  anaesthetic  is  seldom 
required,  as  these  patients  are  so  tolerant  as  to  suggest  that  they  are 
considerably  less  sensitive  than  ordinary  individuals,  and  to  support 
the  belief  that  their  condition  is,  in  some  manner,  related  to  nerve 
defects. 

Rectum. — In   the    rectum   the    condition    is  described    as   "  bal- 
looning ;  "    and  great  importance  was  formerly  attached  to  this,  as  a 


IDIOPATHIC     DILATATION 


135 


sign  of  obstruction  in  the  bowel  above.  It  is  now  known  to  be 
produced  by  a  number  of  other  conditions,  and  less  importance  is 
therefore  attached  to  it  now. 

Urinary  Bladder. — Acute  dilatation  is  one  of  the  most  common 
sequehe  of  operations.  Of  the 
chronic  form,  my  personal  ex- 
perience is  limited  to  two  cases. 
In  one,  the  dilated  bladder  was 
that  of  a  boy,  on  whom  I  per- 
formed sigmoid  colostomy,  for 
chronic  idiopathic  dilatation  of 
the  colon.  The  other  was  a  boy, 
aged  9.  who  was  admitted  to  the 
Infirmary  under  my  care  in  1909, 
for  an  abdominal  swelling.  He 
always  had  a  prominent  abdo- 
men ;  but  four  years  ago  it  began 
to  get  larger.  Two  years  ago  he 
had  several  fits,  and  the  abdomen 
got  larger  still.  He  had  been 
thirsty  and  tired,  and  passed 
much  urine.  He  often  vomited. 
His  eyelids  latterly  had  been  a 
little  swollen  in  the  morning. 
There  was  no  cedema  of  the  legs. 
The  patient  was  a  fairl}^  healthy- 
looking  boy.  His  abdomen 
measured  27^  inches  at  the  level 
of  the  umbilicus.  The  physical 
signs  were  those  of  a  cystic 
tumour  occupying  the  larger 
part  of  the  abdomen,  and  caus- 
ing marked  distention  {Fig.  121). 
A  catheter  was  passed,  and  an 
enormous  quantity  (not  measured) 
of  urine  was  drawn  off.  It  was 
acid  ;  specific  gravity  1005. 
Albumin  and  blood-casts  present. 
No  sugar.  Urea  5  grains  per 
ounce.  A  catheter  was  tied 
into    the    bladder,    and    left    for 

several  days.  He  afterwards  passed  urine  naturally,  but  the  bladder 
again  gradually  distended,  and  a  catheter  was  passed  on  several 
occasions,    drawing    off    from    90    to    114   ounces    of    urine.     Active 


iji. — Idiopathic  Dilatatiox  of  the 
Bladder. 


136  IDIOPATHIC     DILATATION 

contractions  of  the  bladder  wall  could  be  seen  and  felt  whilst  it 
was  emptying.  The  passage  of  a  catheter  appeared  to  cause  him 
no  discomfort ;  and  the  bladder  distention  so  little  inconvenience, 
that  he  would  allow  twenty-four  hours  to  pass  before  asking  to 
micturate. 

Both  cases  were  characterized  by  the  presence  of  intermittent 
abdominal  enlargement,  due  to  enormously  distended  bladders,  which 
gave  rise  to  no  pain,  and  did  not  seem  to  affect  the  health  seriously. 
Neither  patient  resented,  or  appeared  to  feel  any  discomfort  during, 
the  passage  of  a  catheter. 

Uterus.  —  A  rare  condition,  undescribed  in  gynaecological 
treatises,  occurs  in  the  uterus.  It  is  usually  discovered  by  accident, 
during  a  routine  examination,  and  may  be  verified  by  an  operation 
done  under  a  mistaken  diagnosis.  The  uterus  enlarges  (in  one  of 
my  cases  to  the  size  of  a  three  months'  pregnancy,  its  cavity 
measuring  six  inches),  and,  in  consequence  of  its  weight  and  the 
softness  of  its  walls,  is  apt  to  retroflex  ;  then  the  soft  enlarged  fundus 
in  Douglas's  pouch  is  mistaken,  before  operation,  for  a  cyst,  and 
after  it,  for  a  pregnancy.  The  enlargement  may  remain  for  months 
without  S3'mptoms,  and  eventually  disappear. 

Gall- Bladder. — Several  cases  are  recorded  in  which  enormous 
thick-walled  gall-bladders  occupied  so  much  of  the  abdominal  space 
as  to  be  mistaken  for  ovarian  cysts.  Careful  search  had  failed  to 
show  an}'  mechanical  obstacle. 

Common  Bile-duct. — On  one  occasion  I  saw  a  young  girl 
operated  upon  for  an  abdominal  cyst  the  size  of  a  child's  head.  It 
was  in  the  upper  part  of  the  abdomen,  and  on  opening  it  bile  escaped. 
At  the  post-mortem  examination  the  cyst  was  found  to  be  due 
to  enormous  distention  of  the  common  bile-duct.  The  duodenal 
opening  of  this  was  normal,  and  no  mechanical  obstruction  could 
be  found. 

Ureters.  —  The  enormous  double  ureter  distention  of  some 
newly-born  babies  is  well-known ;  and  it  is  also  recognized  that  no 
satisfactory  mechanical  explanation  of  it  has  been  forthcoming  at 
the  post-mortem  examination.  A  similar  condition  may,  though 
rarely,  be  observed  in  adults. 


Some  Functions  of  the  Omentum. 

A  special  protective  agency  exists  in  the  abdomen,  but  for  which 
many  abdominal  diseases  and  operations  would  be  attended  by  a  much 
higher  mortality  than  they  are.  The  omentum,  in  addition  to  other 
uses,  may  be  regarded  as   the   "  abdominal   policeman  "  {Fig.   122). 


SOME    FUNCTIONS    OF    THE    OMENTUM       137 


F/i?.  122. — Normal  Omextim  Formixg  a  Proxectixg  pad  over  the  Intestines. 


Fig.  123. — Radical  Ct-re  of  an  INGL^NAL  Herxia 

BY  Omentum  which  has  Occluded  the  Hernial 

Sac. 


Fig.    124. — OirEXTUM   Occluding   a   Femoral 
Hernial    Sac. 


138       SOME    FUNCTIONS    OF    THE    OMENTUM 

It  travels  about  in  the  abdomen  with  considerable  activity,  and  is 
attracted,  by  some  sort  of  information,  to  neighbourhoods  in  which 
mischief   is  brewing.     It  may  effect    a  radical  cure   of    hernia,  by 


125. — Ojientum  Occluding  the  Sac  of  an- 
Umbilical  Hernia. 


Fj?.    126. — Omentum    Guarding    a    Sltpurating 
Gland  in  the  Mesentery  of  the  Small  Intestine. 

Note  that  the  omentum  has  found  its  way  to  the 
root  of  the  mesentery,  not  allowing  trifling  obstacles 
to  prevent  its  migrations. 


blocking  the  hernial  orifice  with  an  omental   plug  {Figs.  123,  124, 
and  125).     It  surrounds,  and  adheres  to,  a  recently  reduced    stran- 


127. — Omenti'M   Occlcdino  a   Hole  Caused 
BV  Injury  in  the  Jjiai-hracjl 


Fif;.  128. — Omentum  Isolating  a  Suppurating  or 
Gangrenous  Gall-bladder. 

In  acute  cases  the  oedcmatous  vascular  omental 
nest  in  which  the  gall-bladder  lies  is  a  striking  object. 


SOME    FUNCTIONS    OF    THE    OMENTUM       139 

gulated  and  damaged  loop  of  intestine  ;  and  may  keep  it  alive  and 
prevent  a  leak.  It  is  generally  found  in  the  neighbourhood  of  a 
diseased   or   inflamed  appendix  ;    by  wrapping  it  up  if  gangrenous, 


Fig.   129. — O-MExirji  Isolating  the  Appendix  in 
THE  Flank. 

An  abscess  is  frequently  localized,  and  pus  pre- 
vented fronx  escaping  into  the  peritoneum,  by  the 
omentiun. 


Fis^.   130. — Omentum  Isolating  the  Appendix  in 
THE  Ii.iAC  Fossa. 

The  wholly  gangrenous  and  perforated  appendix 
may  be  so  wrapped  up  in  omentum  as  to  prevent 
its  septic  contents  from  escaping  into  the  peritoneal 
cavitv. 


or  by  locking  up  the  pus  from  an  appendix  abscess,  it  may  prevent 
general  peritonitis  {Figs.   129,    130,  and   131).     In  a  similar  manner 


-Omentum  Isolating  the  Appendix  in 
Pelvis. 


Fji,'.    132. — Omentum    Guarding    a    BLalignant 
Ulcer  of  the  Rectum. 

Note  that  it  has  gone  to  the  floor  of  the  pelvis. 


it  may  prevent  the  perforation  of  an  ulcerating    malignant  growth 
{Figs.    132,    133,   and   134),    of    a   gastric    ulcer,    or   the   death  of  a 


no       SOME    FUNCTIONS    OF    THE    OMENTUM 

damaged  portion  of  bowel  {Fig.  135),  or  the  perforation  of  a 
suppurating  gall-bladder  {Fig.  128).  When  it  is  found  covering  and 
closely  enveloping  an  ovarian  cyst  or  a  fibroid  tumour  of  the  uterus, 


Fig.  133. OlIENTUlI  GU.\RDING  A  MALIGN.^^T  ULCER 

OF  THE  vSlGJIOID  FLEXURE  OF  THE  COLON. 

It  is  only  when  an  ulcer  is  threatening  to  perforate, 
or  inflamniation  of  the  growth  has  occurred,  that  the 
omentum  will  be  found  adherent  to  a  cancer.  Under 
ordinary  circumstances  it  appears  to  avoid  contact 
with  it. 


Fk.  I34-- 


-OiiENTUJi  Guarding  a  JL\lignant  Ulcer 
OF  THE  Colon. 


Some  of  the  most  unpleasant  surgical  surprises 
are  encountered  in  this  connection.  The  case  may 
be  regarded  as  one  of  abdominal  abscess,  and  an 
operation  is  perhaps  lightly  undertaken.  .Separation 
of  the  adherent  omentum  opens  the  abscess  and 
exposes  a  septic  sloughing  malignant  growth. 


even   though   not    adherent,   it    is    safe    to    assume   that   something 
wrong  will  be  found  in  the  tumour.     Its  effective  mobihty  is  shown 


Fig.    135. 


-Omentum   Surrounding    an    I-njured 
piece  of  small  inte.stine. 


In  less  than  four  hours  the  omentum  will  be  found 
attached  to  damaged  intestine,  and  many  lives  have 
been  saved  by  the  cn\(loping  omentum. 


Fig.  136. — Omentum  Isolating  a  Pelvic  Tumour, 
degenerating    myoma,    ovarian    cyst,    ectopic 
Gestation,  Pyosalpinx,  etc. 

The  normal  relation  of  the  omentum  to  an  ovarian 
tumour  or  a  fibroid  of  the  uterus  is  above  and  around. 
If  it  lies  in  front,  or  is  adherent,  this  is  definite 
evidence  that  there  is  something  wrong  with  the 
tumour. 


SOME    FUNCTIONS    OF    THE    OMENTUxM       JU 

by  the  fact,  that,  whether  the  lesion  be  in  the  diaphragmatic  roof 
of  the  abdomen  {Fig.  127),  or  on  the  floor  of  the  pelvis  {Fig.  132), 
there  the  omentum  can  and  docs  find  its  way  {Figs.  123  to  138.*) 

Another  function  special  to  the  omentum  is  an  extraordinary 
capacity  for  the  formation  of  new  blood-vessels.  Wherever  it  adheres 
new  blood-vessels  develop  with  great  rapidity,  and  where  the  con- 
tinued need  for  them  arises  they  may  reach  a  considerable  size.  I 
have  excised  large  and  well-nourished   ovarian  tumours  deprived  of 


Fis 


-Omentum  Sealing  an  Ulcer  of  the 

STOM-VCH. 


Fig.   138. — Omentum  Sealing  an  Ulcer  of  the 
Duodenum. 


their  ordinary  vascular  suppl}^  by  an  attack  of  torsion,  and  depending 
for  their  life  on  large  omental  vessels.  The  only  uterine  fibroids 
which  can  attain  to  colossal  size  are  either  retroperitoneal,  or  depend 
chiefly  upon  vessels  derived  from  the  omentum  for  their  continued 
growth.  The  largest  I  ever  removed  was  of  the  subperitoneal 
variety.  It  had  a  thin  and  narrow  pedicle  below,  but  above  was 
capped  by  omentum,  w'hich  carried  to  it  at  least  half  a  dozen  arteries 
of  the  size  of  the  brachial. 


*  These  drawings  are  reprints  from  the  British  Medical  Journal,  of  January  13th, 
1906,  and  were  made  for  me  by  Mr.  Richardson  to  iUustrate  cases  we  had  observed. 


U2  INDICATIONS     FOR     OPERATION 


INDICATIONS    FOR    OPERATION. 

The  most  indisputable  reasons  that  can  be  offered  in  favour  of 
an  operation  are  (i)  That  it  is  to  arrest  hcEniorrhage  ;  (2)  To  prevent 
sepsis  ;    or  (3)   To  remove  a  focus  of  disease. 

I.  Haemorrhage. — The  blood-flow  from  any  vessel  can  be  imme- 
diately arrested  by  pressure  with  the  tip  of  a  finger  on  the  bleeding 
point.  In  order  to  stop  haemorrhage  permanently,  the  first  step 
should  be,  to  see  the  bleeding  point. 

Arterial. — It  is  no  longer  a  rule  to  tie  the  bleeding  artery 
above  and  below  the  opening,  and  thus  occlude  it ;  and  the 
larger  and  more  important  the  artery,  the  worse  such  a  procedure 
would  be.  It  is  possible,  by  suture,  either  to  close  an  arterial 
opening,  or  to  make  an  anastomosis  and  conserve  the  circulation 
through  the  vessel. 

To  see  the  bleeding  point  may  require  an  extensive  operation  ; 
but  this  is  usually  the  lesser  of  two  evils,  and  generally  the  only  safe 
course.  In  certain  conditions,  the  ordinary  treatment  cannot  be 
carried  out. 

Bleeding  from  the  Scalp  is  arrested  with  difficulty  by  nature's 
means,  because  the  great  aids  to  arrest,  retraction  and  contraction 
of  its  blood-vessels,  cannot  occur  owing  to  the  density  of,  and  their 
adhesion  to,  the  tissues  of  the  scalp.  For  the  same  reason,  a  ligature 
is  difftcult  to  apply.  If  pad-pressure  fails  to  stop  the  bleeding,  it 
can  always  be  effected  by  the  skilful  use  of  needles  and  thread,  which 
will  act  at  the  same  time  as  ligatures  and  sutures. 

Bleeding  from  the  Palmar  and  Plantar  Arches  is  usually  also 
an  exception  to  the  rule  as  to  seeing  the  bleeding  point.  On 
account  of  the  inelasticity  of  the  parts,  even  a  large  incision  may  not 
permit  of  this,  while  an  extensive  incision  is  sure  to  inflict  damage  on 
the  important  structures  underneath  the  plamar  or  plantar  fasciae. 
But  the  bleeding  is  likely  to  be  serious,  and  is  unlikely  to  stop  until 
the  bleeding  point  is  effectually  blocked.  Taking  the  hand  for 
example,  the  following  steps  should  be  taken  : — 

1.  Apply  a  tourniquet  to  the  upper  arm. 

2.  Use  every  means  to  ensure  the  absence  and  prevention  of 
sepsis  by  the  use  of  cleansing,  sterilization,  and  antiseptics. 

3.  Pack,  carefully  but  thoroughly,  into  the  bottom  of  the  wound, 
a  small  pad  of  sterile  gauze,  soaked  in  iodine  tincture.  On  this  place 
a  similar  but  somewhat  larger  pad,  and  on  this  a  larger  still,  until  a 
thick  conical  composite  pad  (graduated  compress)  projects  upwards 
from  the  palm.      Holding  this  in  position,  apply  narrow  rolls  of  lint 


INDICATIONS     FOR     OPERATION  U3 

along  the  course  of  the  lower  two-thirds  of  the  radial  and  ulnar 
arteries,  on  the  front  of  the  forearm.  (The  course  of  the  radial  artery 
is  indicated  by  a  line  drawn  from  the  middle  of  the  bend  of  the  elbow 
to  the  base  of  the  styloid  process  of  the  radius,  and  of  the  lower  two- 
thirds  of  the  ulnar  artery,  by  a  line  drawn  from  the  tip  of  the  internal 
condyle  of  the  humerus  to  the  radial  side  of  the  pisiform  bone.) 

4.  Apply  a  padded  splint  to  the  back  of  the  forearm,  reaching 
from  the  elbow  to  the  tips  of  the  fingers,  and  bandage  it  on  carefully 
but  firmly,  from  below  upwards,  leaving  the  finger  tips  exposed.* 

5.  With  the  patient  in  bed,  elevate  the  limb  to  a  position  at 
as  nearly  a  right  angle  as  convenient,  and  remove  the  tourniquet. 
A  convenient  method  of  securing  elevation  is  by  the  application  of  a 
long  broad  strap  of  adhesive  plaster,  folded  over  the  end  to  form  a 
loop ;  and  fixed,  over  the  splint  and  bandages,  to  the  back  and  front 
of  the  forearm.  The  loop  can  then  be  fastened  to  a  hook  in  the 
ceiling,  or  to  the  horizontal  pole  of  a  French  bedstead  or  other  suitable 
apparatus. 

The  after-treatment  consists  in  letting  the  arm  down  in  twenty- 
hours  ;  taking  the  splint  and  padding  off  the  forearm  in  forty-eight 
hours,  when  the  patient  can  be  allowed  to  get  up  and  use  a  sling. 
Unless  there  is  pain,  or  rise  in  temperature,  the  dressing  need  not 
be  disturbed  for  a  week.  It  can  then  be  soaked  off  in  boracic  lotion, 
and  the  wound  dressed  in  an  ordinary  way. 

Secondary  Haemorrhage  in  this  situation,  as  elsewhere,  is  the 
result  of  sepsis,  and  may  be  unusually  troublesome.  The  proper 
treatment  for  secondary  haemorrhage  in  ordinary  wounds  is  to  try 
to  arrest  it  with  the  iodine  pad  previously  described,  as  a  first  step ; 
and  if  recurrence  takes  place  to  secure  the  bleeding  vessel  with  a 
ligature  above  and  below  the  opening  in  it ;  for  a  recurrence  of  bleeding, 
in  these  circumstances,  admits  of  no  further  trifling,  and  must  be 
tackled.  In  the  hand,  as  this  procedure  is  not  possible,  the  pads  should 
be  reapplied,  and  the  brachial  artery  ligatured.  A  similar  operation 
may  be  required  elsewhere,  when  it  is  impossible  to  apply  a  ligature 
at  the  bleeding  spot. 

Bleeding  from  an  Incised  Tonsillar  Abscess  may  be  very 
serious,  and  is  often  difficult  to  stop.  A  small  piece  of  disinfected 
sponge  dipped  in  turpentine,  packed  into  and  left  in  the  cavity,  will 
occasionally  arrest  it  when  all  ordinary  means  have  failed. 

On  one  occasion  I  was  asked  to  see  a  child  two  years  of  age,  with 
haematemesis  and  meLnena  of  one  week's  duration.  It  was  nearly 
dead ;  had  a  waxy  skin  ;    was  dropsical  from  anaemia  ;   and  fainted 


*  Complaint  that  a  bandage  is  too  tight  must  never  be  disregarded.     No  mistake 
has  been  followed  by  more  serious  consequences. 


Ul  INDICATIONS     FOR     OPERATION 

when  its  head  was  raised.  There  was  no  sign  of  anything  wrong 
in  its  abdomen.  On  examination  of  the  mouth,  after  depressing  the 
tongue,  I  saw,  with  the  greatest  ease  and  distinctness,  a  Httle  artery 
pumping  at  the  bottom  of  a  smah  crack  far  back  on  the  dorsum  of 
the  tongue.  With  a  thick  knitting-needle  and  a  cork,  a  cautery 
was  improvised  wliich  arrested  the  bleeding  at  once,  and  permanently. 
The  child  slowty  recovered. 

Bleeding  from  the  Nose  that  has  resisted  the  ordinary  remedies, 
keeping  the  arms  raised  above  the  head,  pinching  the  nose,  and 
breathing  through  the  mouth,  etc.,  may  be  so  serious  as  to  demand 
active  measures.  At  times,  with  a  good  illumination,  retractors, 
and  sponging,  it  is  possible  to  see  a  bleeding  vessel  on  the  septum  ; 
when  this  has  been  blocked  the  bleeding  ceases.  More  commonly, 
it  is  not  possible  to  find  the  source  of  the  bleeding,  and  pressure,  by 
some  form  of  dressing,  is  necessary.  For  many  years,  plugging  the 
posterior  nares  was  regarded  as  the  only  resort  in  serious  cases  ;  but 
the  discomforts  of  it  were  such  as  to  be  apt  to  make  the  most  heroic 
rebelhous  ;  and  it  was  not  without  danger,  for  septic  inflammation 
of  the  middle  ear  was  a  not  infrequent  result.  By  careful  plugging 
through  the  anterior  nares  it  is  possible  to  arrest  any  ordinary  haemor- 
rhage from  the  nose.  Gauze  (preferably  iodoform-formalin-glycerin), 
cut  in  the  form  of  a  square  of  sufficient  size,  is  pushed  by  forceps 
pressing  on  its  centre,  along  the  floor  of  the  nose  to  the  back  of  it. 
The  edges  of  gauze,  at  the  nostril,  are  then  opened  up  to  display  the 
projecting  mouth  of  the  pocket,  and  the  pocket  is  steadily  filled  by 
strips  of  gauze  ;  first  directly  backwards,  along  the  floor  ;  next  upwards 
and  backwards  towards  the  floor  of  the  orbit ;  and  finally,  directly 
upwards.  The  hardness  of  this  plug  can  be  increased  by  pressure 
on  the  core,  and  traction  on  the  edges  of  the  pocket.  It  is  necessary, 
before  leaving  the  patient,  to  be  sure  that  blood  is  not  escaping 
down  the  throat.  Watch  for  the  gulping  efforts  attending  swallowing 
under  such  circumstances,  and  examine  the  back  of  the  throat. 

The  same  general  rule  for  treatment  applies  to  internal  as  to 
external  hcTmorrhage,  namely,  to  see,  if  possible,  the  bleeding  point  ; 
but  there  are  many  exceptions  to  this. 

The  diagnosis  of  haemorrhage  if  blood  is  passed  from  the 
stomach,  bowels,  lungs,  rectum,  bladder,  kidney,  or  uterus,  etc.,  may 
be  easy  ;  but  if  it  is  not  passed,  or  cannot  escape  externally,  other 
signs  have  to  be  looked  for.  The  characteristic  signs  are  :  pallor — 
especially  noticeable  in  the  lips  ;  a  quick  and  increasingly  feeble 
pulse  ;  anxiety  and  restlessness  ;  and  a  cold  clammy  sweat  on  the 
forehead.  When  these  are  all  present,  it  is  a  surgical  certainty  that 
the  condition  is  very  serious  ;  that  haemorrhage  is  going  on  some- 
where ;    and  that  the  only  known  method  of  arresting  it  is  to  tie  the 


INDICATIONS     FOR     OPERATION  145 

bleeding  point.  These  three  conchisions  are  wholly  true  of  intra- 
peritoneal bleeding,  because  the  peritoneum  seems  to  possess  similar 
properties  to  the  intima  of  the  blood-vessels,  and  to  delay  blood- 
clotting  ;  but  experience  proves  that  they  are  not  to  be  regarded  as 
a  demand  for  surgical  activity  in  the  great  majority  of  cases  in  which 
blood  escapes  externally.  For  example,  bleeding  from  the  stomach, 
however  sudden  and  severe,  is  seldom  fatal  ;  and  the  bleeding  rarely 
fails  to  cease  spontaneously.  If  it  recurs,  it  may  do  so  several  times 
without  a  fatal  result.  Without  this  knowledge,  a  surgeon  would 
conclude  that  such  a  severe  sudden  bleeding  came  from  a  vessel  so 
large  that  spontaneous  arrest  was  impossible  ;  and  that  recurrence, 
like  the  secondary  haemorrhage  he  was  accustomed  to  deal  with, 
was  the  result  of  sepsis  ;  and  that,  after  a  single  return,  it  was  sure 
to  appear  again  and  again,  until  death  followed.  Not  only  centuries 
of  experience,  but  operative  calamities,  have  been  necessary  to 
convince  some  surgeons  that  these  conclusions  might  be  wrong.  It 
is,  however,  now  generally  agreed  that  recurrent  h?emorrhage  from 
gastric  ulcer  is  an  indication  for  gastro-enterostomy,  and  one  of  the 
best  reasons  for  performing  it. 

2.  Sepsis. — Such  empirical  rules  as  ''  Trephine  in  all  compound 
fractures  of  the  skull,"  and  "  Sutures  in  scalp  wounds  are  dangerous," 
were  based  upon  the  experience  that  trephining  added  to  the  chance 
of  recovery  (it  did  so  by  diminishing  the  chance  of  septic  meningitis)  ; 
and  that  suture  of  scalp  wounds  was  more  frequently  followed  b}- 
erysipelas,  suppuration,  and  other  septic  complications,  than  when 
the  wounds  were  left  open.  Neither  of  these  rules  would  be  accepted 
as  a  guide  to  practice  now  ;  but  operations  on  the  head  are  still 
necessary  for  the  prevention  of  sepsis.  It  is  impossible  to  exaggerate 
the  importance  of  thorough  exploration,  except  for  the  most  trivial 
scalp  wound.  But  for  a  rule  based  upon  this  knowledge,  always 
to  feel  or  to  see  the  bottom  of  the  wound,  it  is  certain  that  foreign 
bodies  will  continue  to  be  left  in  scalp  wounds,  and  that  punctured 
and  perforating  fractures  of  the  skull  and  brain  will  be  found  as  an 
unpleasant  surprise  at  post-mortem  examinations.  An  injur}^  to  the 
head,  which  is  to  be  fatal  in  four  da^^s,  may  leave  a  patient  "  quite 
well,"  and  "  fit  for  anything."  Operation  on  these  cases,  for  the 
prevention  of  sepsis,  will  save  many  lives. 

Case  6. — A  schoolbo}^  aged  i6,  was  firing  a  toy  cannon  which  burst. 
An  hour  later  I  saw  him  with  what  was  regarded  as,  and  appeared  to  be, 
a  trivial  scalp  wound  over  the  right  frontal  eminence  near  the  margin 
of  the  hairy  scalp. 

He  made  no  complaint  ;  talked  and  looked  well,  and  walked  some 
distance  with  me  to  a  private  hospital.    A  probe,  introduced  into  the  wound. 

10 


146 


INDICATIONS     FOR     OPERATION 


entered  the  skull  through  a  punctured  fracture.  A  disc  of  bone  was  removed 
with  the  trephine,  and  the  breach  of  the  cannon  was  found  lying  in  a  hole 
in  the  dura  mater.  (It  consisted  of  a  piece  of  iron,  a  quarter  of  an  inch 
long,  and  of  the  diameter  of  the  end  of  my  httle  finger.)  Several  portions 
of  depressed  fragments  of  the  inner  table  were  also  removed  from  the  right 
frontal  lobe  of  the  brain.  The  wound  was  sutured  with  long  untied 
silkworm-gut  sutures,  and  packed  with  antiseptic  gauze.  Next  day,  the 
temperature  and  pulse  were  normal,  and  the  condition  of  the  wound  was 
satisfactory  ;  consequently,  the  gauze  was  removed,  and  the  sutures  were 
permanently  tied.     Recovery. 


Fig.    139. 


-Photograph  showing  Wound  of  Face  from  which  the  piece  of  Hay   Fork. 
AS  shown   on   the  opposite  page,   was   Extracted. 


Case  7. — Two  years  before  admission  to  my  wards  in  the  Royal 
Infirmary,  a  boy,  aged  10  years,  had  fallen  off  a  hay-cart,  and  was 
carried  home  unconscious.  He  was  carrying  a  hay-fork  at  the  time, 
and  this  was  found  to  be  broken.  A  large  wound  on  the  right  side 
of  the  scalp  and  face  was  cleansed  and  sutured,  not  probed,  and  it 
healed  by  first  intention. 

Two  years  later,  the  wound  "began  to  gather."  A  small  abscess 
formed  and  healed,  and  after  a  few  months  a  black  object  protruded 
through  the  skin  {Fig.  139).     A  piece  of  hay-fork  four  and  a  half  inches 


IXDICATIOXS     FOR     OPERATION 


147 


long  was,  to  the  surprise  of  every  one  concerned,  readily  withdrawn  from 
the  wound  (Fig.  140.)  It  had  apparently  passed  through  the  antrum  of 
Highmore.  and  crossed  the  back  of  the  naso-pharynx  to  the  opposite  side. 
The  bov  fortunately  suffered  no  ill  effects  ;  but  his  case  conveys  a 
useful  lesson. 


Fig.   140. — Foreign  Body   (Piece  of  Hay  Fork). 
Removed  from  wound  in  head  of  boy  more  than  two  years  after  an  injury. 


The  majority  of  compound  fractures  that  go  wrong,  at  the  present 
day,  are  those  with  "  a  very  small  wound  which  was  sealed  with 
collodion."  Operation,  for  the  removal  of  foreign  bodies  and  dirt, 
%vould  have  prevented  sepsis  and  saved  many  useful  limbs. 

10a 


148  INDICATIONS     FOR     OPERATION 

Injuries  and  wounds  of  the  abdominal  parietes  may  be  compli- 
cated by  lacerated  wounds  of  the  viscera  and  internal  haemorrhage 
in  patients  who  "■  have  only  been  winded,  and  have  now  quite 
recovered."  Unless  a  rule  is  adopted  that  an  operation  shall  be  done 
to  see  the  full  extent  of  the  wound  (the  peritoneum  must,  of  course, 
not  be  opened  unless  it  has  been  perforated),  many  lives  will  be  lost 
by  preventible  sepsis. 

Case  8. — During  the  period  of  office  of  Dr.  Coates  as  my  house-surgeon,. 
I  was  leaving  the  Infirmary  after  a  hard  morning's  work  (5th  June,  1902). 
We  met  at  the  door  a. patient  walking  with  a  friend.  They  had  come  six 
miles  to  the  Central  Station  by  train.  It  would  have  been  diffiicult  to  say 
which  was  the  patient  and  which  the  friend,  for  neither  looked  as  if  there- 
could  be  much  wrong.  Their  story  was,  that  they  had  been  playing  with 
cartridges  and  the  lire,  three  hours  before,  and  an  explosion  had  driven 
something  against  the  patient's  abdomen  causing  a  small  wound,  which 
bled  a  good  deal  and  made  him  faint.  The  patient  asked  that  a  dressing 
should  be  applied  ;  that  he  should  be  allowed  to  return  home  at  once  ;  and 
he  resented  the  suggestion  that  there  might  be  some  serious  damage  done, 
or  that  any  operation  was  necessary. 

On  enlarging  the  wound,  a  hole  was  found  leading  into  the  peritoneal 
cavity.  On  extending  the  opening,  free  bleeding  was  seen  to  be  going  on, 
and  more  than  a  pint  of  blood  had  already  escaped  into  the  abdomen.  The 
source  of  it  was  traced  to  an  artery,  pumping  in  the  omentum ;  and  this  had 
been  divided  by  the  brass  end  of  a  cartridge,  three-quarters  of  an  inch 
square,  which  was  found  lying  in  contact  with  it.  The  artery  was 
ligatured ;  the  foreign  body  removed ;  the  peritoneum  and  the  wound  were 
cleansed  ;  and  recovery  followed. 


The  dangers  of  septic  foci,  and  the  importance  of  operations 
for  their  removal,  are  not  yet  sufficiently  recognized.  The- 
majority  of  cases  of  ill-health ;  a  great  number  of  diseases  not 
associated  with  their  true  origin  (e.g.,  varieties  of  arthritis)  ; 
and  many  deaths,  arise  from  sepsis,  which  can  only  be  prevented 
by  removal  of  the  focus  of  infection.  Mouth,  ear,  throat  and 
nose  sepsis,  for  example,  deserve  more  recognition  than  they  have 
yet   received. 

The  mortality  and  ill-success  of  operations  is  now  chiefly  dependent 
upon  the  failure  to  realize,  or  inability  to  act  upon  the  belief,  or  both,, 
that  prevention  of  sepsis  should  be  an  all-sufftcient  indication  for 
operation. 

Surgical  tuberculosis  is  rarely  fatal  except  from  septic  complica- 
tions, and  these  can  usually  be  prevented  by  operation.  The 
kidney  destruction,  and  the  mortality  following  bladder  and  kidney 
operations,  result  from  these  operations  being  left  undone  when, 
they  might  have  prevented  sepsis. 


INDICATIONS     FOR     OPERATION  149 

Delay,  till  sepsis  has  got  so  good  a  hold  that  it  cannot 
be  arrested,  is  the  cause  of  90  per  cent  of  the  mortality 
after  operations  for  appendicitis,  gall-stones  and  intestinal  ob- 
struction. 

3.  To  Remove  a  Focus  of  Disease. — For  a  variable  time,  often 
for  long,  disease  remains  localized  to  the  spot  in  which  it  started. 
Operation  at  this  period  is  hkely  to  prevent  further  infection  and 
generalization.  Sepsis,  tubercle,  and  cancer,  each  supply  abundant 
evidence  as  to  the  truth  of  this,  and  to  the  failure  of  the  most  heroic 
operations  undertaken  at  a  later  stage. 

The  Surgical  History  of  ovariotomy  may  offer  a  useful  lesson 
for  future  guidance.  Twenty-five  years  ago,  ovarian  tumours  removed 
by  operation  were  of  colossal  size ;  and  the  mortality  of  the  operation 
was  not  less  than  25  per  cent.  So  long  as  it  remained  at  that,  a  dread 
of  the  risk  kept  patients  from  seeking  relief,  till  the  necessity  for  it 
was  apparent  to  all.  Hence  the  size  and  complications  of  the 
tumours.  Ten  years  later,  many  women  with  pelvic  pain  had 
their  ovaries  removed.  The  chief  reasons  were  that,  as  nothing 
else  was  found  to  account  for  their  pain,  therefore  the  ovaries  must 
be  at  fault;  and  the  technique  of  the  operation  had  made  such 
strides  that  it  was  now  safe  to  remove  them.  Pathologists  generally 
discovered  something  wrong  in  the  excised  ovaries  ;  but  the  patients 
found,  after  recovery  from  the  operation,  that  not  only  was  the 
pain  still  there,  but  other  troubles  had  developed  in  addition.  This 
is  a  frequent  after-history  when  operations  of  any  sort  have  been 
performed  for  the  relief  of  symptoms  in  the  absence  of  physical 
signs  of  gross  disease.  At  the  present  time,  it  is  known  that 
ovarian  tumours  seldom  remain  stationary,  but  as  a  rule  make 
steady  progress  ;  that  many  contain  cancer  locked  up  in  them  ; 
that  their  diagnosis  at  any  stage  is  easy,  when  there  is  a  definite 
tumour ;  that  their  removal  is  safe,  and  that  the  results  are 
then   satisfactory. 


True  advance  in  surgery  is,  to  a  certainty,  not  to  be  expected  in 
the  direction  of  bolder  operating;  but  through  increased  knowledge 
of  etiology,  pathology,  diagnosis,  and  prognosis  ;  so  that  the  earliest 
manifestations  of  disease  may  be  recognized  in  time  to  prevent  the 
serious  happenings  so  frequently  dealt  with  now. 


150 


X-RAYS 


X-RAYS. 

The  advantages  of  .r-rays  as  an  aid  to  diagnosis  and  treatment 
are  even  yet  not  sui!iciently  appreciated. 

Tlie    following   photographs    {Figs.    141    to    146)    are    intended 

to    illustrate   these    points. 


Fig.   141. — "  Sprained  Wrist." 
Colles'  fracture,  impacted— little  deformity. 


X-RAYS 


151 


Fis.   142. — "  Sprained  Wrist." 
Showing  fracture  of  scaphoid  bone,  also  CoUes'  fracture. 


152 


X-RAYS 


Fig.   143. — Extra  Capsulak  TRACTrRE  of  the  Neck  of  the  Femur. 
"  Contused  hip."     Patient  able  to  walk. 


X-RAYS 


153 


Fig.  144. — llETAL  Pencil  Case  in  Right  Broxchls. 
Removed  after  performance  of  low  tracheotomy 


J  54 


X-RAYS 


Fig.  145. — Tooth  plate  Impacted  in  the  (Esophagus. 


X-RAYS 


155 


Fig.  146. — Acute  Septic  Osteitis  of  the  Metacarpal  Bone  of  the  Ring  Finger. 

An  illustration  of  the  aphorism— There  is  no  such  thing  as  an  acute  primary  cellulitis  in  children. 
Always  look  for  a  bone  focus.  The  child  was  sent  into  the  infirmary  with  "  cellulitis  of  the 
hand  and  forearm." 


\ 


157 


INDEX 


ABDOMINAL  pain,  causes  of     .  . 
characters  of 

—  and  pelvic  viscera,  the  .  . 
—  acute  inflammation  of    .  . 

—  —  —  cause  of  colics  of 

—  —  —  chronic  inflammation  of 

—  colics  of     .  . 

— a  course  of     .  . 

effect  of  complete  obstruc- 
tion on  the  caecum 

gall-bladder    .  . 

urinary  bladder 

inflammation  and  ob- 
struction on  hollow  viscera 

—  partial  obstruction  on 

gall-bladder 
stomach 

—  —  —  —  —  —  urinary  bladder 

gangrene  of 

gall-bladder    .  . 

intestine 

urinary  bladder 

—  —  vermiform  appendix 

—  —  —  the  hollow  viscera 

—  —  —  reaction  to  stimuli  of 

—  tubercle  of 

Abscess,  causes  of    .  . 

—  course  of  .  . 

—  healing  of 

—  delayed  healing  of 

—  signs  of      .  . 
Acute  inflammation,  causes  of 

—  —  method  of  causation 
Agglutination  as  a  defence  against 

micro-organisms 

Antibacterial  defence  against  micro- 
organisms 

Antiseptic,  definition  of 

Antitoxins 

Appendicitis,  association  with  pyaemia 

Arthritis,  pysemic 

in    relation    to     other     joint 

diseases 

Asepsis,  definition  of 


PAGE 
130 

III 
III 
112 
112 
112 
112 


114 


"3 

112 

116 

116 

117 

116 

117 

112 

112 

1X2 

17 

17 

17 

17 

18 

16 

16 


22 

19 
22 
12 


19 


Bacilli 

Bacteria,  action  of,  in  wounds 

—  conditions  of  growth  of 

—  destruction  of     . . 

—  diffusion  of,  in  body 

—  divisions  of 

—  general  changes  produced  by,  in 

body    . . 

—  local   changes   produced   by,    in 

body    .  . 

—  localization  of,  in  body.  . 

—  where  found  in  nature  .  . 
Bandage,  dangers  of  tight  .  . 
Bedsores  and  gangrene 
Bile-duct,  idiopathic  dilatation  of  the 
Bleeding,    tendency    to,    chieflA'    an 

individual  character 
Blood  as  a  defence  against  micro- 
organisms 
Blood,  transfusion  of,  in  cancer 
Bone    injuries,      association      with 
pyaemia 

Calculi 

Calculus  behaves  as  a  foreign  body 

—  cause  of  symptoms  of    . 
bladder 

—  —  —  renal 

—  large,  symptoms  of 

—  prognosis  of 

—  symptoms  of        .  . 

—  treatment  of 
Callous  ulcers,  treatment  of 
Cancer 

—  absence    of    early    pathognomic 

signs    .  . 

—  characters  of  the  tumour  of 

—  chorion  epithelioma,  peculiarities 

of 

—  classification  of 

—  columnar-celled 

—  en  cuirasse 

—  diagnosis  of 

—  electricity  in 

—  epithelioma 


PAGE 

19 


19 

20 


19 


20 
20 
20 

143 

44 
I3<J 

103 

22 
95 


121 
121 
121 

121 
121 
123 
123 
121 


12 


40 
83 

90 

88 

89 

88 

89 
89 
89 

94 

88 


158 


INDEX 


Cancer,  epithelioma,  secondary  glan- 
dular infection 

—  exciting  cause  of.  . 

—  favourite  sites  of 

—  general   condition   as   an   aid   in 

diagnosis 

—  importance  of  chronic  irritation 

—  —  discovery  of   tumour 

—  —  haemorrhage   .  . 

—  —  precancerous  conditions 

—  —  signs  of  stricture 

—  infection  of  glands 

—  methods  of  commencing 

—  open-air  treatment  of     .  . 

—  palliative  operations 
— •  points  in  prognosis 

—  predisposing  causes  of   .  . 

—  principles    of     radical     car 

operations 

—  prognosis  of  .  .  .  . 

—  rodent  ulcer 

—  secondary  growths,  characters  of 
chief  seats  of 

—  spheroidal-celled 

—  spontaneous     healing     of     face 

epithelioma     .  . 

—  transfusion  of  blood  in 

—  treatment  of 
by  operation  .  . 

—  ulcer  characters  of 
Cellulitis,  diffuse  suppuration,  causes 

of         

—  general  symptoms  of      .  . 

—  local  signs  of 

Chronic  inflammation,  causes  of    . 
Cocci    .  . 

Colon,  idiopathic  dilatation  of  the. 
Congenital  syphilis   .  . 

—  —  general  appearance  .  . 

—  —  later  signs  of .  . 

—  —  signs  of 

in  anus  and  genitals 

—  —  —  in  bones  and  joints 

—  in  mouth  .  . 

in  skin 

in  skull 

Contusions,  dangers  of 

—  signs  of      .  . 

—  terminations  of    .  . 

—  treatment  of 


88 

87 
88 

92 
91 
91 
91 
93 
91 
87 
87 
95 
94 
92 
83 

93 
92 


95 
93 
93 


16 

19 

134 

70 
71 
71 
70 
70 

71 

70 

70 

70 

104 

104 

104 

104 


Diabetic  gangrene 


48, 


Erysipelas,  causes  of 

—  course  of  .  . 

—  duration  of 

—  incubation  period 

—  prognosis  of 

—  signs  of     .  . 

—  symptoms  of 

—  treatment  of 

—  varieties  of 


Fever,  general  inflammatory 
Fibrosis  as  a  defence  against  micro 

organsims 
—  in  malignant  diseases     .  . 
Fistula,  definition  of 
Function,  impairment  of      . . 


PAGE 

28 
28 
29 
29 
29 
28 
28 
29 
29 


22 

58 

17 

5 


EccHYMOsis,  large,  suggest  fractures 
Electricity  in  cancer 
Embolism  and  gangrene 
Epistaxis,  plugging  nares    .  . 
Erysipelas 


ICJ4 
94 
44 

144 

28 


Gall-bladder,  idiopathic  dilatation 

of  the  . . 
Gangrene  of  abdominal  and  pelvic 

viscera 

—  acute  infective  localized 

—  —  —  —  causes  of 
signs  of 

—  —  —  —  treatment  of  .  . 
spreading 

—  —  —  causes  of  .  . 

prognosis  of 

signs  of      .  . 

—  —  —  treatment  of 

—  and  bedsores 

—  best  method  of  amputation  in . 

—  cause      of      clinical      differences 

between  dry  and  moist 

—  causes,  exciting  .  . 

—  —  predisposing  .  . 

—  circulation  in,  methods  of  testing 

—  clinical  differences  between  dry 

and  moist 

—  diabetic     .  .  .  .  .  .  48, 

—  difference  between  ordinary  and 

infective,  involving  prepuce 

—  from  embolism     .  . 

—  experimental,  to  produce  dry 
to  produce  moist 

—  from  frostbite,  treatment  of 

—  fully-developed,  treatment  of 

—  of  gall-bladder     .  . 

—  of  intestine 

—  from  ligature  and  embolism 

—  line  of  demarcation 

—  method  of  prevention  of  nioist 

—  —  separation  of  dead  from  living 

part 

—  natural  amputation,  defects  of 

—  ordinary,  essential  difference  from 

infective 
-      -  relation  to  vascular  supply.  . 


136 

116 

41 
42 

42 
42 
42 
42 
42 
42 
42 
44 
53 

44 
43 
43 


44 
52 

42 
44 
43 
43 
51 
50 
116 
117 

51 
46 

44 

46 
46 

42 
42 


INDEX 


159 


Gangrene,  premonitory  signs  of  dia 
betic 


Raynaud's  disease 

.        48 

—  —  —  senile 

.        48 

—  senile 

52 

—  and  slough 

42 

—  summary  of  causes  of     .  . 

45 

■ —  threatening,  treatment  of 

.        48 

—  traumatic,  treatment  of 

50 

—  treatment  of 

.        48 

—  and  ulcers .  . 

32 

—  of  urinary  bladder 

.      116 

—  vermiform  appendix 

•      "7 

Glands,  cancer  infection  of 

■        87 

Gleet 

31 

Gonococci,  clinical  course  of 

29 

—  duration  of  anterior 

30 

—  methods  of  spread 

29 

Gonorrhoea     .  . 

29 

—  abortive  treatment  of     .  . 

30 

—  affecting  posterior  urethra 

31 

—  cause  of    .  . 

29 

' —  complications  of.  in  men 

31 

—  —  in  women 

32 

—  general  complications  of 

32 

—  modes  of  infection 

29 

—  and  sterility 

32 

—  treatment  of 

30 

—  in  women .  . 

31 

H.-^MOPHILIA 

•      103 

—  history  of  typical  case    .  . 

•      103 

Haemorrhage,  arterial 

.      142 

—  in  cancer,  importance  of 

91 

—  internal  signs  of .  . 

•      144 

—  intraperitoneal     .  . 

•      144 

—  from  nost,.  . 

•      144 

—  operation  for  arrest  of  .  . 

•      141 

—  from  palmar  and  plantar  arche 

s     142 

—  —  —  —  treatment  of  .  . 

.      142 

—  from  scalp 

■      142 

—  secondary. . 

•      143 

from  palm,  treatment  of 

•      143 

treatment  of  .  . 

•      143 

—  from  stomach 

■      144 

treatment     by     gastroenter 

ostomy 

•      145 

—  from    tongue    simulating   haema 

temesis 

•      143 

—  from  tonsillar  abscess     .  . 

•      143 

—  treatment  of 

•      144 

Hjemorrhoidal  vein,  association  witl 

pj^acmia 

13 

Healing 

2 

Hodgkin's  disease 

•        58 

Hollow     viscera,     characters     of 

diverticulum  .  . 

.      119 

sacculus    .  . 

•      119 

Hollow  viscera,  essential  differences 
between  diverticula  and 
sacculi 

—  —  diverticula  and  sacculi 

—  —  pathological  changes  in  di\er- 

ticula  and  sacculi.  . 

—  —  —  and     clinical     results     of 

diverticula  and  sacculi 

—  —  reaction  of,   to  calculi 
—  to  foreign  bodies 

—  of     symptoms     produced 

by  calculi 

—  —  reasons  why  diverticula  and 

and  sacculi  are  confu.sed 

Idiopathic  dilatation 
acute   .  . 

—  —  of  common  bile  duct 
chronic 

of  gall-bladder 

ureters 

urinary  bladder 

—  —  uterus 

Indications  for  operation,  to  remove 

a  septic  focus 
Infection,  microbic   .  . 

—  septic 

Infective  organisms,  clinical  signs  of 

special  infection 
Inflammation,  causes  of 

—  —  exciting 

—  —  predisposing   .  . 

—  as     a     defence     against     micro- 

organisms 

—  definition  of 

—  due  to  traumatism,  rheumatism. 

and  gout 

—  exciting  causes    .  . 

—  general  predisposing  causes 

—  general  signs  of  .  . 

—  heat  in 

—  local  predisposing  causes 

—  loss  of  function  in 

—  pain  in 

—  —  character  of   .  . 

—  —  tender  spot  in 

—  pathological 

—  physiological 

—  redness  in .  . 

—  results  of  .  . 

—  signs  of      .  . 

—  signs  of  local 

—  swelling  in 

—  terminations  of   .  . 

—  —  general 

—  —  local     .  . 

Intestine,  idiopathic  dilatation  of.  . 

—  inversions  of  the.  . 


119 
119 


119 


136 
131 
136 
136 

136 

149 

20 

O3 

16 
I 
I 

I 


13 
I 

15 

4 

5 

15 

2 

I 

13 

3 

3 

3 

13 

15 

17 

15 

132 

123 


160 


INDEX 


PAGE 

Intestine,  torsions  of  the      .  .           .  .  126 

Inversions       .  .           .  .           .  .           .  .  123 

—  acute  and  chronic           .  .           .  .  124 

—  causes  of  . .           . .          . .           . .  123 

—  essential     cause     of     differences 

between  acute  and  chronic.  .  124 

—  of  the  intestine   .  .          .  .           .  .  123 

Iodine,  glycogen  reaction    .  .          .  .  23 

Joints,  sarcoma  of  . .          .  .          .  .  100 

—  and  viscera,  pj'aemic  abscesses  in  13 

Keloid  and  Sarcoma           .  .           .  .  97 

Leucocytosis            .  .           .  .           .  .  21 

—  aid  of  in  diagnosis  and  prognosis  21 
Lungs,  embolism  of  sarcoma  in  .  .  97 
Lymphatic  glands,  sarcoma  of       .  .  98 

Malignant  disease  .  .           .  .           .  .  82 

definition  of   .  .           .  .           .  .  82 

general  consideration  of       .  .  53 

Mastoid    disease,    association    with 

pyaemia            .  .           .  .           .  .  8 

Melanotic  cancer       .  .           .  .           .  .  98 

Micro-organisms,    defences   of  body 

against             .  .          .  .           .  .  22 

agglutination               .  .  22 

—  —  —  —  antibacterial  substances  22 

— —  blood   .  .           .  .           .  .  22 

- —  —  —  —  fibrosis              .  .           .  .  22 

—  inflammation              .  .  22 

— —  phagocytosis  .  .           .  .  22 

• —  skin      .  .           .  .           .  .  22 

Middle-ear    suppuration,    cause    of 

pyaemia           .  .           .  .           .  .  8 

MoUuscum   fibrosum   in   relation   to 

sarcoma           .  .           .  .           .  .  96 

Xares,  plugging  of  the        .  .           .  .  144 

Xose,  to  arrest  bleeding  from          .  .  144 

(Esophagus,  idiopathic  dilatation  of 

the       . .           . .           . .           . .  131 

Omentum  as  the  abdominal  police- 
man    .  .           .  .           .  .           .  .  136 

—  effective  mobility  of       .  .           .  .  140 

—  ferrets  out  seat  of  trouble        .  .  138 

—  some  functions  of  the     .  .           .  .  136 

—  protection  of,  in  appendicitis  .  .  139 
— ^  as    a    protection     to     damaged 

intestine          .  .           .  .           .  .  138 

fibroid  tumour  of  uterus     .  .  140 

gall-bladder    .  .           .  .           .  .  14 

—  —  ovarian  cyst  .  .           .  .           .  .  140 

ulcers  .  .          .  .           .  .           .  .  139 

—  radical  cure  of  hernia     .  .           .  .  138 

—  travels  of  the       .  .           .  .           .  .  138 


Open-air  treatment  of  cancer 
Operation  for  arrest  of  haemorrhage 

—  indications  for 
Opsonic  index 

Ovariotomy,  history  of,  as  a  guide 
to  the  requirements  of  ad- 
vance in  surgery 

Paralytic  ileus 

Pathological  inflammation,  causes  of 

—  phenomena  of     .  . 

Primary    focus,    importance    of,    in 

pyaemia 
Primary  syphilis 

Psoas  abscess,  operative  treatment  of 
Puerperal    fever,    association    with 

pyaemia 
Pyaemia 

—  arrest  of,  by  ligature  of  veins 

—  association  with  appendicitis 

bone  injuries 

haemorrhoidal  vein 

—  mastoid  disease   .  . 

—  —  —  puerperal  fever    .  . 

—  causes  of  .  ., 

—  clinical  signs  of  .  . 

—  importance  of  primary  focus   . 
repeated  rigors 

—  natural  prevention  of,  by  throm 

bosis    .  . 
Pyaemic    abscesses    in    viscera    and 
joints  . . 

—  arthritis     .  . 
relative  to  other  joint  diseases 

—  comparison    with    acute    and 

gonorrhoeal  rheumatism 

—  resemblances  to  acute  and  gonor 

rhoeal  rheumatism     .  . 

Rectum,  ballooning  of 
Repair,  characters  of 
Repair  of  special  parts 
Rigors  in  pyaemia     .  . 

Sapr.^mia 

Sarcoma,  classification  of    .  . 

—  desmoid,  of  abdominal  wall 

—  diagnosis  of 

—  —  bone  by  A'-rays 

—  embolism  of 

—  —  in  lungs 

—  exceptional      methods     of      dis 

semination 

—  and  injury 

—  of  joints    .  . 

—  and  keloid 

—  of  lymphatic  glands 

—  melanotic 


PAGE 

95 
141 
141 

23 


149 

132 
12 

2 

14 
65 
80 

13 

8 

14 
12 

8 
13 
13 
13 

8 

13 

14 
14 

13 

13 
15 
15 


134 

I 

2 

13 


96 
99 
99 

97 

97 

98 
96 

lOO- 

97 


9& 


INDEX 

161 

PACE 

PAGE 

Sarcoma,    nature    of    secondary  de- 

Suppuration . . 

17 

posits 

98 

—  diffuse,  course  of 

18 

—  no  age  limit 

90 

—  of  middle  ear,  cause  of  pyaemia 

8 

—  predisposition     to,     by     certain 

—  signs  of      .  . 

18 

simple  tumours 

96 

Syphilis,  cause  of      .  . 

64 

—  the  primary  lesion  of     .  . 

97 

—  character  of  primary  sore 

05 

—  prognosis  of 

100 

—  congenital 

70 

—  reasons  for  lymphatic  dissemina- 

— —  general  appearance  of 

71 

tion 

98 

signs  of 

70 

—  its  relation  to  certain  scars 

96 

—  diagnosis  of  chancre 

65 

to  molluscum  fibrosum  .  . 

96 

secondary  lesions 

66 

—  to  tooth  sepsis     .  . 

97 

—  general  considerations  of           .  .  - 

3-64 

—  results  of  experimental  work  on 

—  gummata  of  bones 

68 

treatment  of  . . 

102 

—  —  muscle 

68 

—  symptoms  and  signs 

100 

skin 

68 

—  of  testicle .  . 

98 

—  infectiveness  of   .  . 

71 

—  tonsil 

98 

—  late  secondaries  .  . 

66 

—  treatment  of 

102 

—  marriage  in 

74 

by  alternative  methods,  ,r-rays 

—  methods  of  contracting 

64 

and  Cole^-'s  fluid   .  . 

102 

—  primary     .  . 

65 

desmoid  tumours 

90 

—  prognosis  in 

74 

by  operation  .  . 

102 

—  secondary 

65 

- —  usual  methods  of  dissemination 

97 

—  stages  of  . . 

65 

Sarcomata 

95 

—  tertiary      .  .           .  .           .  .              6 

5,  67 

—  essential  similarity  to  cancers  .  . 

95 

—  —  gumma 

67 

—  histological  characters    .  . 

96 

of  blood-vessels 

69 

—  predisposing  causes 

96 

—  —  brain  and  spine 

69 

Scalp,  haemorrhage  from,  to  arrest 

142 

—  —  eyes 

69 

—  wounds,  importance  of  thorough 

mouth 

68 

exploration  of 

145 

nose     . . 

69 

sepsis  of 

145 

rectum 

69 

Secondary  syphilis    .  . 

65 

viscera 

69 

Senile  gangrene 

48 

signs  of 

67 

Sepsis  and  abdominal  injuries 

14b 

—  treatment  of 

72 

—  compound  fractures 

146 

—  —  condylomata 

73 

—  definition  of 

19 

—  —  constitutional 

72 

—  old  aphorisms  concerning 

145 

—  —  infants 

73 

—  prevention    and    arrest    of,     by 

—  —  iritis     .  . 

73 

operation 

145 

local  conditions 

73 

—  of  scalp  wounds  .  . 

145 

in  mouth 

73 

—  still     the     greatest     danger     of 

—  skin 

73 

operations 

149 

—  throat 

73 

—  tubercle,  and  malignant  disease, 

nervous  symptoms    .  . 

73 

importance  of  disease  focus  in 

149 

—  —  primary  sore  .  . 

72 

—  foci,  dangers  of    .  . 

147 

tertiary 

73 

Septic    focus,    indications     for    re- 

— Wasserman  reaction 

71 

moval  of 

149 

Syphilitic  ulcers,  treatment  of 

41 

Septicaemia     .  . 

17 

Sinus,  definition  of   .  . 

17 

Temperature  and  pulse 

23 

Skin,  the,  as  a  defence  against  micro- 

Tertiary syphilis 

65 

organisms 

3  2 

Testicle,  sarcoma  of .  . 

98 

Spirilla 

19 

Tonsil,  sarcoma  of     .  . 

98 

Sterilization,  definition  of   .  . 

19 

Tonsillar  abscess,  bleeding,  to  arrest 

143 

Stomach,  acute  dilatation  of 

131 

Tooth,  septic,  and  sarcoma.  . 

97 

—  idiopathic  dilatation  of  the 

131 

Torsion,      commencement     of     the 

Strangulation  in  hernia 

131 

attack 

130 

Stricture  as  sign  of  cancer.  . 

91 

—  importance  of  length  of  pedicle  in 

131 

Subacute  inflammation,  causes  of.  . 

16 

—  progress  of 

130 

162 


INDEX 


Torsion,  repeated  attacks  of 

130 

—  strangulation  in  .  . 

131 

—  treatment  of 

131 

Torsions 

124 

—  causes  of  .  . 

129 

—  complete  volvulus 

126 

— •  direction  of 

129 

—  of  intestine 

126 

—  necessary  requirements  for 

126 

—  of  ovarian  tumours 

126 

—  partial  volvulus  .  . 

127 

—  pathological  changes 

129 

—  primary     .  . 

126 

— ■  secondary 

127 

—  sigmoid  volvulus 

127 

—  symptoms  of 

130 

Toxins 

224 

Tubercle,  general  considerations  of 

53 

Tuberculin,     treatment     of     tuber 

culosis  by 

78 

Tuberculosis  .  . 

74 

—  aids  in  diagnosis  of 

77 

—  Bier's  treatment .  . 

79 

—  cause  of     .  . 

7 

—  cold  abscess 

75 

—  composition  of  a  tubercle 

75 

—  course  of  tubercle 

75 

—  diagnosis  of  cold  abscess 

75 

size  and  source  of  sinus 

76 

—  general  treatment  of       .  . 

78 

—  injection  treatment  of    .  . 

79 

—  local  treatment  of 

79 

at  different  ages .  . 

79 

—  mode  of  entrance 

74 

—  natural  cure  of  tubercle .  . 

75 

—  operative  treatment  of  .  . 

80 

— Psoas  abscess 

80 

—  opsonic  index  of .  . 

78 

—  pathology  and  formation  of  cole 

abscess 

75 

—  predisposing  causes 

74 

—  preventive  operation 

82 

—  treatment  of,  by  tuberculin 

78 

—  type  of  patients  .  . 

75 

Tuberculous  ulcers,  treatment  of  . 

40 

Tumour  as  sign  of  cancer    .  . 

91 

Tumours,  ovarian,  torsions  of 

126 

Ulcer,  extending  or  healing  ? 

■        38 

■ —  and  gangrene 

32 

—  causes  of  defective  blood  supply 

n      32 

tuberculous 

40, 


Ulcer,   diagnosis  of  .. 

from  base 

character  of  discharge   .  . 

— character  of   surrounding 

skin  .  . 

—  —  —  condition  of  patient 

edge 

— locality 

—  —  —  multiplicity 
pain 

—  —  —  shape 

—  general  treatment  of 

—  ideal  treatment  of 

—  local  treatment  of 

—  Martin's    bandage,     method 

application 

—  predisposing  causes  of   .  . 

—  and  skin  grafting 

—  treatment  of 
special,    callous, 

and  syphilitic 

—  varieties  of 

Ureters,  idiopathic  dilatation  of  the 
Urinary  bladder,  acute  dilatation  of 
Uterus,  idiopathic  dilatation  of  the 

Vaccines 

Viscera  and  joints,  pyaemic  abscesses 

in 
Volvulus  of  the  intestine     .  . 

Wounds 

—  accidental,  dressing  of  . 

—  —  treatment  of  .  . 

—  aims  of  surgeon  in 

—  aseptic 

—  avoidance  of  irritants  in 

—  classification  of   .  . 

—  continuous  elastic  pressure  in 

—  differences  from  contusions 
— •  divisions  of 

—  healing,  methods  of 

—  methods  of  preventing  sepsis  in 

—  retention  of  heat  in 

—  treatment  of,  antiseptic  method 

—  treatment  of,  general  principles 

—  treatment  of,  Lister's  methods.  . 

X-RAYS  as  an  aid  to  diagnosis  and 
treatment 


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III 
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2975.10  JOHN    WRIGHT    AND    SONS    LTD.,     PKINTERS    AND     PUBLISHERS      BRISTOL. 


PLATE     I. 


INFLAMMATION     OF     THE     FINGER     EXTENDING     UP     THE     FOREARM. 


PLATE     II. 


Fig.  A. — Pus  FROM  Carbuncle  of  Neck. 

Showing  staphylococci.       Diplococcal  and  tetrad  fonns. 
Bunches. 


Fig.  B. — Pus  FROM  Urethra. 

Showing  gonococci  in  leucocytes  and  free  squamous  urethral 
cells. 


Fig.  C. — Spiroch.t:t.\  Pallida. 
From,  a  caae  of  syphilis. 


Fi^.  D. — Streptococci  in  Pus. 
From   a   case  of    infective    meningitis. 


PLATE     III. 


Fi^.'A. — Bi.ooD    Film,    normal. 


Fig.   C— LEfcocYTOSls.  — From  a  case  of  lateral  sinuf  thrombosis. 


PLATE     IV. 


SUDE     PREPARED     FOR     OPSONIC     IXDEX. 

Showing  tubercle  bacilli  in  leucocyte?. 


PLATE     V. 


Gangrene. 
a.  The  line  of  demarcation. 


(Q 


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